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. Place a pillow under the child's head: Protecting the head prevents injury from impact with the floor during the seizure. Using a pillow or folded blanket cushions the head while allowing the seizure to run its course safely.
B. Restrain the child's upper extremities: Restraining movements during a seizure can cause fractures, dislocations, or soft tissue injury. The nurse should allow the seizure to occur naturally while ensuring the environment is safe.
C. Place a padded tongue blade in the child's mouth: Inserting any object into the mouth is unsafe and can cause dental injury, aspiration, or airway obstruction. Current guidelines advise against this practice.
D. Turn the child onto their back: Placing a child supine during a seizure increases the risk of airway obstruction and aspiration. The recommended position is lateral (side-lying) to maintain airway patency and allow secretions to drain.
Correct Answer is C
Explanation
A. The website URL is listed as com: A ".com" domain indicates a commercial site and does not guarantee the accuracy or credibility of health information. Commercial sites may have marketing motives that can bias the content.
B. The author's name is listed without credentials: Listing an author without credentials does not provide verification of expertise in the medical field. Credible health information should be authored or reviewed by qualified healthcare professionals.
C. The author cites references to statements made: Providing references to scientific studies or reputable sources demonstrates that the information is evidence-based and allows verification. Cited references indicate that the content is grounded in credible medical research, enhancing trustworthiness.
D. The website was last updated 3 years ago: Health information can become outdated quickly. A last update from several years ago may not reflect current guidelines or best practices, reducing the reliability of the resource.
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