A nurse is caring for a client who has depression.
After two days of treatment, the nurse notices that the client is suddenly more active and there are no longer signs of a depressive state.
Which of the following interventions should the nurse recommend for the plan of care?
Monitor the client’s whereabouts at all times.
Encourage family to take the client out of the facility for short periods of time.
Ask the client why her behavior has changed.
Reward the client for her change in behavior.
The Correct Answer is A
Answer and explanation
Choice A rationale:
Impaired judgment is a cognitive symptom of schizophrenia, not a positive symptom. It involves difficulties with decisionmaking, problem-solving, and understanding consequences. While it's a significant feature of schizophrenia, it doesn't reflect an excess or distortion of normal functions, which is the hallmark of positive symptoms.
Choice B rationale:
Dysphoria refers to a depressed mood or a state of unhappiness and dissatisfaction. It's a negative symptom of schizophrenia, characterized by a decrease or absence of normal functions. It's not considered a positive symptom as it doesn't involve an excess or distortion of normal processes.
Choice C rationale:
Disorganized speech is a hallmark positive symptom of schizophrenia. It involves significant disruptions in the way a person speaks and communicates. It can manifest in several ways, including: Derailment: Abrupt shifts in topic without logical connection
Tangentiality: Responding to questions in irrelevant or oblique ways
Incoherence: Speech that is fragmented and difficult to understand
Loose associations: Combining words or phrases in a way that lacks logical sense
Neologisms: Creating new words or phrases that have meaning only to the speaker
Word salad: Severely disorganized speech that is essentially incomprehensible
Disorganized speech is considered a positive symptom because it reflects an excess or distortion of normal speech processes. It's a core feature of schizophrenia and often has a significant impact on communication and social functioning.
Choice D rationale:
Anhedonia is the inability to experience pleasure. It's a negative symptom of schizophrenia, characterized by a decrease or absence of normal emotional responses. It's not considered a positive symptom as it doesn't involve an excess or distortion of normal processes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice D rationale:
Lithium toxicity is a serious and potentially life-threatening condition. It can occur when lithium levels in the blood become too high.
Blurred vision and nausea are common early symptoms of lithium toxicity.
Withholding the medication is the most important action the nurse can take to prevent further toxicity and potential harm to the client.
The nurse should immediately notify the healthcare provider of the client's symptoms and the decision to withhold the medication.
The healthcare provider will likely order a lithium level to be drawn to assess the severity of the toxicity.
Depending on the results of the lithium level, the healthcare provider may order other interventions, such as intravenous fluids or medications to lower the lithium level.
Choice A rationale:
Encouraging the client to rest with his eyes closed may provide some temporary relief from the blurred vision, but it does not address the underlying problem of lithium toxicity.
It is important for the nurse to take more decisive action to prevent further toxicity.
Choice B rationale:
Re-checking the client in 4 hours may delay necessary interventions and allow the lithium toxicity to worsen.
It is important for the nurse to take immediate action to protect the client's health.
Choice C rationale:
Administering the next dose of lithium as prescribed would further increase the lithium level in the blood and could lead to more severe toxicity.
This is not a safe or appropriate action for the nurse to take in this situation.
Correct Answer is D
Explanation
Choice A rationale:
Increased salivation is a common side effect of haloperidol, but it is not the most serious adverse effect that the nurse should monitor for. It can be managed with medications such as anticholinergics, and it often subsides with continued use of haloperidol. Choice B rationale:
Serotonin syndrome is a rare but potentially life-threatening condition that can occur when haloperidol is combined with other medications that increase serotonin levels, such as antidepressants. However, it is not a direct adverse effect of haloperidol itself.
Choice C rationale:
Increased menstrual bleeding is not a known side effect of haloperidol.
Choice D rationale:
Tardive dyskinesia is a serious and potentially irreversible movement disorder that can occur as a long-term side effect of haloperidol and other antipsychotic medications. It is characterized by involuntary, repetitive movements of the face, tongue, and limbs.
The risk of tardive dyskinesia increases with the length of time that a person takes haloperidol and with the dose of the medication.
There is no cure for tardive dyskinesia, but the symptoms can sometimes be managed with medications.
It is important for nurses to monitor patients who are taking haloperidol for signs of tardive dyskinesia, so that the medication can be discontinued if necessary.
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