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. “Are you thinking of hurting yourself?”: This response directly and calmly assesses for suicidal ideation, which is essential when a client expresses feelings of worthlessness or passive death wishes. Asking clearly about self-harm allows the nurse to determine risk and initiate appropriate safety interventions.
B. “What would your family do without you?”: This response may increase guilt or emotional distress rather than encouraging open communication. It does not assess the client’s immediate safety or suicidal thoughts.
C. “When you get better you will not feel this way.”: This response minimizes the client’s current feelings and may make the client feel unheard or dismissed. It does not address potential suicidal risk or provide emotional support.
D. “Why would you think a thing like that?”: Asking “why” can sound judgmental and may discourage the client from sharing further. It does not assess for suicidal intent and may increase defensiveness or withdrawal.
Correct Answer is B
Explanation
A. Reduced anxiety: While anxiety may improve with overall health stabilization, it is not a direct indicator of potassium replacement effectiveness. Potassium primarily affects neuromuscular and cardiac function rather than emotional state.
B. Normal sinus rhythm: Hypokalemia can cause cardiac arrhythmias. The presence of a normal sinus rhythm indicates that potassium levels have been corrected and the heart’s electrical activity is stabilized, reflecting a positive response to supplementation.
C. Decreased urinary output: Changes in urinary output are not a direct measure of potassium replacement effectiveness and may indicate other complications, such as renal impairment or fluid imbalance.
D. Decreased blood pressure: Blood pressure changes are not a direct outcome of potassium supplementation and could suggest unrelated cardiovascular issues. Normalization of cardiac rhythm is a more specific indicator of intervention success.
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