A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse document as positive symptoms of schizophrenia? (Select all that apply.)

Flight of ideas

Decreased motivation

Impaired memory

Delusions of grandeur

Auditory hallucinations

Answer and Explanation

Correct Answer : A,D,E

Positive symptoms of schizophrenia are those that add something to the normal experience, such as hallucinations, delusions, disorganized speech, and abnormal motor behavior. Flight of ideas is a type of disorganized speech that involves rapid switching from one topic to another. Delusions of grandeur are false beliefs of having superior power or status. Auditory hallucinations are hearing voices or sounds that are not real. Negative symptoms of schizophrenia are those that take something away from the normal experience, such as decreased motivation, impaired memory, flat affect, and social withdrawal.

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Correct Answer is B

Explanation

The priority for the nurse is to assess the client's safety and risk of self-harm or suicide, which may increase during a situational crisis. The other questions are also important to explore, but they are not as urgent as assessing for suicidal ideation or intent.

A. Weigh the client every other day. B. Plan a menu with the client. C. Remain with the client for 1 hr after meals D. Offer snacks when the client is hungry.

Correct Answer is C

Explanation

A. Weigh the client every other day – Frequent weighing can increase the client’s focus on weight, potentially adding stress and anxiety, which is not beneficial for managing binge eating disorder.
B. Plan a menu with the client – Although planning meals can be helpful, remaining with the client after meals is more directly aimed at preventing bingeing behaviors.
C. Remain with the client for 1 hr after meals – Staying with the client after meals helps to monitor for any signs of binge eating behavior and provides support, reducing the likelihood of excessive eating episodes.
D. Offer snacks when the client is hungry – Unstructured snacking can promote impulsive eating and does not assist the client in establishing controlled eating patterns.

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A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse document as positive symptoms of schizophrenia? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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