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 A
Explanation
The correct answer is Choice A.
Choice A rationale:
Having consistent unit routines can provide a sense of stability and predictability, which can be beneficial for a client in the manic phase of bipolar disorder.
Choice B rationale:
Providing a stimulating environment can potentially exacerbate symptoms of mania, making it an inappropriate intervention.
Choice C rationale:
Scheduling daily seclusion times is not typically recommended as it can lead to feelings of isolation.
Choice D rationale:
Discouraging daytime napping can potentially lead to fatigue and worsen symptoms, so it’s not typically recommended.
Correct Answer is A
Explanation
Choice A rationale:
Medication compliance is crucial in the management of BPD because:
Instability and Impulsivity: Individuals with BPD often struggle with impulsivity and unstable moods, which can lead to inconsistent medication adherence. They may forget to take their medications, take them at the wrong times, or stop taking them altogether when they feel better or worse. This can disrupt the therapeutic effects of the medications and increase the risk of relapse or worsening symptoms.
Multiple Medications: BPD is often treated with a combination of medications, such as mood stabilizers, antidepressants, and antipsychotics. Each medication has its own unique dosing schedule, side effects, and potential for interactions. Monitoring compliance ensures that the client is taking all medications as prescribed, reducing the risk of adverse events and optimizing treatment outcomes.
Mental Health Stigma: Unfortunately, mental health stigma can contribute to medication noncompliance. Individuals with BPD may feel ashamed or embarrassed about their diagnosis, leading them to hide their medication use or avoid taking medications altogether. By openly discussing medication compliance and addressing any concerns, nurses can help reduce stigma and promote adherence.
Therapeutic Relationship: A strong therapeutic relationship between the nurse and client is essential for promoting medication compliance in BPD. Nurses can foster trust and open communication by:
Actively listening to the client's concerns about medications.
Providing clear and concise education about the purpose and benefits of medications.
Collaborating with the client to develop a medication regimen that fits their lifestyle and preferences.
Regularly assessing medication adherence and addressing any barriers to compliance.
Offering support and encouragement to the client throughout the treatment process.
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