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

Answer and Explanation

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.

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Correct Answer is ["A","B","D","F","G"]

Explanation

A. Monitor blood pressure: The client’s blood pressure readings (148/94 mm Hg and 156/96 mm Hg) indicate hypertension in pregnancy, which requires frequent monitoring to detect worsening preeclampsia and prevent complications such as stroke or placental abruption.

B. Check urinary output: Elevated BUN and creatinine, along with proteinuria, indicate possible renal involvement from preeclampsia. Monitoring urinary output helps assess kidney function and detect oliguria, a critical warning sign.

C. Initiate contact precautions: There is no evidence of an infectious condition requiring contact precautions. Standard precautions are sufficient for this client.

D. Monitor deep tendon reflexes: Hyperreflexia (DTR 3+) is a hallmark sign of preeclampsia and indicates increased seizure risk. Ongoing monitoring is essential for early recognition of worsening neurological status.

E. Assist with preparing the client for amniocentesis: Amniocentesis is not indicated based on the current clinical findings. Immediate priorities involve maternal stabilization and fetal monitoring, not diagnostic invasive procedures.

F. Encourage bedrest: Bedrest can help reduce blood pressure and improve uteroplacental perfusion in clients with preeclampsia. Positioning the client on her left side optimizes blood flow to the fetus and kidneys.

G. Assist with application of internal fetal monitor: The client has minimal variability on the external fetal monitor, suggesting potential fetal compromise. Internal fetal monitoring may be indicated for more accurate assessment of fetal status, so assisting with its application is appropriate.

A. Secure the tubing with adhesive tape to the lower abdomen. B. Instruct the client to hold the drainage bag at waist height when ambulating C. Coil the tubing on the bed above the collection bag. D. Collect a sterile specimen from the urinary drainage bag

Correct Answer is A

Explanation

A. Secure the tubing with adhesive tape to the lower abdomen: Properly securing the catheter tubing prevents tension on the catheter, reduces the risk of accidental dislodgment, and helps maintain a closed drainage system, which decreases the risk of infection.

B. Instruct the client to hold the drainage bag at waist height when ambulating: The drainage bag should always be kept below the level of the bladder to maintain proper urine flow and prevent backflow, which increases the risk of infection. Holding it at waist height is unsafe.

C. Coil the tubing on the bed above the collection bag: Placing tubing above the collection bag can allow urine to flow back toward the bladder, increasing the risk of urinary tract infection. Tubing should remain below bladder level.

D. Collect a sterile specimen from the urinary drainage bag: Sterile urine specimens should be obtained from a sampling port on the catheter using aseptic technique, not directly from the drainage bag, to avoid contamination.

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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.

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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.