A nurse is caring for a client who has been diagnosed with schizophrenia and appears confused and has distortions in their thinking and speech patterns.
Which of the following is the priority nursing intervention for this client?
Ensure the client goes to group activities as planned.
Use distraction such as the television or music.
Provide reassurance and comfort ensuring the client is safe.
Give PRN medications to treat increased hallucinations.
The Correct Answer is C
Choice A rationale:
Ensuring the client goes to group activities as planned is important, but not the priority when the client is confused and has distorted thinking.
Choice B rationale:
Using distraction such as television or music can be helpful, but it is not the priority intervention.
Choice C rationale:
Providing reassurance and comfort ensuring the client is safe is the priority as it directly addresses the client’s immediate needs.
Choice D rationale:
Giving PRN medications to treat increased hallucinations may be necessary, but it is not the first action to take.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The client is displaying manifestations of lithium toxicity, which includes ataxia and blurred vision. Therefore, the nurse should withhold the medication.
Choice B rationale:
Administering the next dose as prescribed could potentially exacerbate the client’s symptoms and increase the risk of further toxicity.
Choice C rationale:
Propranolol is not typically used in the management of lithium toxicity.
Choice D rationale:
Levothyroxine is used to treat hypothyroidism and is not relevant in this context.
Correct Answer is A
Explanation
Choice A rationale:
Muscle weakness is a manifestation of mild lithium toxicity. Lithium toxicity can occur at therapeutic levels, so clients should be monitored for adverse effects.
Choice B rationale:
Constipation is not typically associated with lithium toxicity. Diarrhea, not constipation, is a symptom of lithium toxicity.
Choice C rationale:
Urinary retention is not a typical symptom of lithium toxicity. Increased urination and thirst are common side effects of lithium.
Choice D rationale:
Hyperactivity is not a typical symptom of lithium toxicity. Lithium is used to manage bipolar disorder and can help reduce hyperactivity.
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