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. "Why do you feel the staff is the FBI”: Asking “why” can sound confrontational and may make the client feel interrogated or defensive. It can increase anxiety and does not provide emotional support. This approach is not therapeutic when a client is experiencing a fixed delusion.

B. "The psychiatric staff is not FBI. They are here to help you.": Directly contradicting the client’s delusion can increase mistrust and agitation in a client with paranoid schizophrenia. This response challenges the belief without acknowledging the client’s emotional experience, which can damage rapport.

C. "This must be very frightening for you, let's talk more about it.": This response acknowledges the client’s feelings without validating the delusion itself. It conveys empathy, reduces anxiety, and encourages further communication. This therapeutic approach helps build trust while gently redirecting focus to the client’s emotional state.

D. "What makes you think the staff is following you”: Although more open-ended than option A, this question encourages the client to further elaborate on the delusion. It risks reinforcing the false belief rather than focusing on emotional support and reality-based care.

A. "I will need to take my medications for a total of 6 weeks." B. “I am no longer contagious." C. "I will need to have someone observe me when I take my medication." D. "I can expect my contact lenses to turn red or orange," E. "I should notify my provider if I start taking new over-the-counter or prescription medications." F. "I can continue my current alcohol intake." G. "I will need to have a repeat Mantoux test in 4 weeks."

Correct Answer is ["C","D","E"]

Explanation

A. "I will need to take my medications for a total of 6 weeks.": TB treatment requires a prolonged course, typically 6 months, not 6 weeks. This statement reflects a misunderstanding of the duration of therapy and could lead to incomplete treatment and drug resistance.

B. “I am no longer contagious.": Clients with active tuberculosis remain contagious until they have received adequate treatment and follow-up testing confirms noninfectious status. Early discharge does not automatically mean the client is no longer a transmission risk.

C. "I will need to have someone observe me when I take my medication.": Directly Observed Therapy (DOT) is recommended to ensure adherence to TB medications, which helps prevent drug resistance and treatment failure. Understanding the importance of DOT indicates comprehension of infection control and treatment compliance.

D. "I can expect my contact lenses to turn red or orange.": Rifampin can discolor body fluids, including tears, causing contact lenses to appear red or orange. Recognizing this harmless side effect demonstrates the client’s understanding of medication effects.

E. "I should notify my provider if I start taking new over-the-counter or prescription medications.": TB medications have multiple drug interactions, and the client must inform the provider of any new medications to prevent adverse effects or reduced drug efficacy.

F. "I can continue my current alcohol intake.": Alcohol use is contraindicated with TB medications because it increases the risk of hepatotoxicity, particularly with isoniazid, rifampin, and pyrazinamide. Continuing alcohol would compromise treatment safety.

G. "I will need to have a repeat Mantoux test in 4 weeks.": Follow-up testing is not required once TB is confirmed by sputum culture. The Mantoux test is used for diagnosis, not monitoring treatment response.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has paranoid schizophrenia and believes that they are being followed by FBI agents who are pretending to be psychiatric staff. Which of the following responses should the nurse make?

Correct Answer is C

Explanation

The nurse is preparing the client for discharge. Which of the following statements indicate the client understands the discharge teaching? Select the 3 client statements that indicate an understanding of the teaching.

Correct Answer is ["C","D","E"]

Explanation

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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.