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 C
Explanation
Choice A rationale:
Taking lithium on an empty stomach is not necessary. Lithium can be taken with or without food.
Choice B rationale:
Excessive salivation is not a common side effect of lithium.
Choice C rationale:
Vomiting or diarrhea can lead to dehydration, which increases the risk of lithium toxicity by reducing the excretion of lithium. Therefore, it’s important to notify your provider if you experience these symptoms.
Choice D rationale:
Decreasing fluid intake can lead to dehydration and increase the risk of lithium toxicity. It’s recommended to maintain a normal fluid intake while taking lithium.
Correct Answer is A
Explanation
Choice A rationale:
A serum lithium level of 1.6 mEq/L is above the therapeutic range (0.6-1.2 mEq/L) and can cause symptoms such as GI discomfort and poor coordination.
Choice B rationale:
Lip smacking and tongue thrusting are not typically associated with lithium toxicity.
Choice C rationale:
While blurred vision can be a symptom of lithium toxicity, jerking motor movements are not typically associated with this condition.
Choice D rationale:
Fever and fluctuating blood pressure are not typically symptoms of lithium toxicity.
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