A nurse is caring for a client in an outpatient clinic.
Select the 3 interventions the nurse should plan to take.
Encourage the client to think positive thoughts.
Assist the client in distinguishing between anxiety and physical manifestations.
Provide relief measures for manifestations the client is experiencing.
Inform the client that nothing is medically wrong with them.
Suggest to the client's provider that multiple tests need to be performed.
Perform a lengthy exam of client's condition.
Correct Answer : B,C,E
A. Encourage the client to think positive thoughts. While promoting positive thinking can be helpful, this approach may oversimplify the client's experience and does not address their anxiety or physical symptoms effectively.
B. Assist the client in distinguishing between anxiety and physical manifestations. This intervention is crucial as it helps the client understand the connection between their anxiety and physical symptoms. It can empower the client to better manage their feelings and reduce their fixation on health issues.
C. Provide relief measures for manifestations the client is experiencing. Addressing the client's physical symptoms, such as anxiety and stomach discomfort, is important for their overall well-being and can improve their quality of life.
D. Inform the client that nothing is medically wrong with them. This statement may dismiss the client's concerns and could lead to feelings of frustration or invalidation. It is important to listen to the client’s experiences without minimizing them.
E. Suggest to the client's provider that multiple tests need to be performed. Given the client's report of ongoing symptoms and concerns about their health, it is appropriate to recommend further evaluation to rule out any underlying medical issues. This ensures that the client feels heard and their concerns are taken seriously.
F. Perform a lengthy exam of the client's condition. Conducting a lengthy exam may not be necessary at this stage, especially in an outpatient setting. Instead, focusing on understanding the client's experience and addressing their concerns is more beneficial.
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Related Questions
Correct Answer is C
Explanation
A. Incoherent speech. Incoherent speech is more characteristic of acute episodes of schizophrenia rather than the prodromal phase. During the prodromal phase, symptoms are typically less severe and may not include full-blown disorganized thinking.
B. Severe delusions. Severe delusions are indicative of an active psychotic phase of schizophrenia. The prodromal phase generally involves milder symptoms that precede the onset of more severe psychotic episodes.
C. Withdrawn behavior. The prodromal phase of schizophrenia is often marked by subtle changes in behavior, including social withdrawal, decline in self-care, and changes in functioning. Withdrawn behavior is a common manifestation during this phase, signaling the beginning of deterioration before the onset of more intense symptoms.
D. Frequent hallucinations. Hallucinations are more commonly seen during the active phase of schizophrenia rather than the prodromal phase. In this early stage, clients may experience less intense symptoms and may not exhibit frequent or vivid hallucinations.
Correct Answer is B
Explanation
A. Fever and fluctuating blood pressure. While lithium toxicity can cause various systemic symptoms, fever and fluctuating blood pressure are not specifically indicative of lithium toxicity and may suggest other medical conditions.
B. Blurred vision and jerking motor movements. A serum lithium level of 1.6 mEq/L indicates toxicity, and common manifestations of lithium toxicity include neurological symptoms such as blurred vision and involuntary movements, including tremors or jerking.
C. Lip smacking and tongue thrusting. These symptoms are more characteristic of tardive dyskinesia or other extrapyramidal symptoms related to antipsychotic medications rather than lithium toxicity.
D. GI discomfort and poor coordination. While gastrointestinal discomfort can occur with lithium toxicity, poor coordination is not as specific as the neurological symptoms like blurred vision and jerking movements. The latter are more closely associated with higher lithium levels.
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