A nurse is assisting in the care of a client who was brought to the emergency department by the police
Select the 4 client findings from the Nurses' Notes that indicate psychosis.
Response to stimuli
Affect
Thought process
Level of orientation
Speech pattern
Physical appearance
Correct Answer : A,C,D,F
A. Response to stimuli: The client was responding to internal stimuli, such as hearing helicopters and believing they are being pursued. Responding to hallucinations is a hallmark sign of psychosis.
B. Affect: Affect refers to the observable expression of emotion. While the client’s agitation and cooperation may be noted, affect alone does not confirm psychosis without evidence of altered perception or thought content.
C. Thought process: The client exhibits disorganized and paranoid thoughts, such as believing the clinic is a laboratory and the nurse is the devil. These delusions indicate impaired thought processes associated with psychosis.
D. Level of orientation: The client is able to state their name but not the date and misinterprets surroundings, demonstrating disorientation and impaired reality testing, which are consistent with psychosis.
E. Speech pattern: The notes do not specifically describe incoherence, flight of ideas, or pressured speech. While speech may reflect agitation, it is not explicitly documented as psychotic.
F. Physical appearance: The client appears disheveled with matted hair and stained clothing, reflecting neglect of self-care, which is often observed in clients experiencing psychosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "I will notify my doctor if the stoma starts to look purple.": A stoma that appears purple can indicate compromised blood flow or ischemia, which is a medical emergency. Recognizing this sign and notifying the healthcare provider demonstrates understanding of proper stoma care and potential complications.
B. "I will irrigate the colostomy every day.": Ascending colostomies typically produce liquid to semi-liquid stool and are not routinely irrigated. Daily irrigation is usually reserved for descending or sigmoid colostomies to regulate bowel movements.
C. "I should expect my stool to be formed.": Stool from an ascending colostomy is usually liquid or semi-liquid because the stool has not yet passed through the majority of the colon where water absorption occurs. Expecting formed stool indicates a misunderstanding of colostomy output.
D. "I will empty the pouch every 2 to 3 hours.": Ascending colostomy output is frequent and liquid, but pouches are generally emptied when they are one-third to one-half full, not on a strict schedule. Overly frequent emptying is unnecessary and may increase the risk of skin irritation.
Correct Answer is B
Explanation
A. “I will need to remain upright for 1 hour after taking the medication.”: Remaining upright after taking medication is typically recommended for medications that may cause esophageal irritation, such as certain tablets or NSAIDs, but pantoprazole does not require this. Upright positioning is not necessary specifically for proton pump inhibitors.
B. “I have to take this medication on an empty stomach.”: Pantoprazole, a proton pump inhibitor, is best absorbed when taken 30–60 minutes before a meal. Taking it on an empty stomach enhances its effectiveness in reducing gastric acid secretion and managing GERD symptoms.
C. “I can take antacids at the same time as this medication.”: Antacids can be taken with pantoprazole, but it is generally recommended to separate the timing by at least 30 minutes to avoid affecting the absorption and effectiveness of the proton pump inhibitor.
D. “I should expect to have diarrhea while taking this medication.”: While diarrhea can be a potential side effect of pantoprazole, it is not expected for every client. Most clients tolerate the medication well without gastrointestinal upset.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.