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 D
Explanation
Choice A rationale:
Stopping medication can be a sign of non-compliance or dissatisfaction with treatment, but it is not a direct warning sign of suicide.
Choice B rationale:
Requesting an appointment to discuss depression is a positive step towards seeking help and managing mental health.
Choice C rationale:
Sleeping 12 hours a day could indicate depression or other mental health issues, but it is not a specific warning sign of suicide.
Choice D rationale:
Giving away possessions can be a warning sign of suicide as it might indicate that the person is putting their affairs in order, which is a serious suicide warning sign.
Correct Answer is B
Explanation
Choice A rationale:
Increased flatulence is not typically associated with lithium toxicity.
Choice B rationale:
Vomiting is a common symptom of lithium toxicity, indicating the client understands the teaching.
Choice C rationale:
While loss of appetite can occur in various conditions, it’s not a specific indicator of lithium toxicity.
Choice D rationale:
Headaches can be caused by various factors and are not specifically associated with lithium toxicity.
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