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 C

Explanation

A. Admission vital signs: While admission vital signs are part of the client’s history, they are not usually relevant for change-of-shift reporting unless there has been a trend or abnormal finding that impacts current care. Reporting outdated vitals does not inform immediate clinical decisions.

B. Steps required for dressing change: Detailed procedural steps are not typically included in shift reports. The report should focus on current status, recent changes, and ongoing care needs rather than teaching or step-by-step instructions.

C. Time of last pain medication: Reporting the time of the last analgesic dose is important for continuity of care. It helps the incoming nurse assess pain control, schedule subsequent doses, and anticipate the client’s comfort needs.

D. Preferred bath time: While client preferences are helpful for planning care, they are not critical information for clinical decision-making during a shift report. This detail can be communicated during routine care rather than formal handoff.

A. Wear cotton underwear. B. Drink orange juice daily for 3 to 4 weeks. C. Take the prescribed antibiotic until manifestations are gone. D. Restrict fluid intake to 1 L per day

Correct Answer is A

Explanation

A. Wear cotton underwear: Cotton underwear allows better air circulation and reduces moisture accumulation, which helps prevent bacterial growth in the genital area. Proper underwear choice is a simple preventive measure that supports urinary tract health.

B. Drink orange juice daily for 3 to 4 weeks: While vitamin C may help acidify urine slightly, there is no evidence supporting long-term consumption specifically for UTI prevention. Excessive intake can also irritate the bladder or cause gastrointestinal upset.

C. Take the prescribed antibiotic until manifestations are gone: Antibiotics should be taken for the full prescribed course, not just until symptoms resolve. Stopping early can lead to incomplete eradication of bacteria and increase the risk of resistance.

D. Restrict fluid intake to 1 L per day: Restricting fluids can worsen UTIs by reducing urine output, which limits bacterial flushing from the urinary tract. Adequate hydration is recommended to help prevent and manage UTIs.

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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.