A nurse is caring for a client who has schizophrenia and is preparing for discharge. Nurses' Notes

Admission:

25-year-old client admitted with positive symptoms of schizophrenia. Client has a history of substance use, anxiety, and depression. Client demonstrates alterations in speech and persecutory delusions. Client states that they hear voices that are warning them of danger and that they should stay away from a coworker because the coworker is conspiring against them. Day 5-Discharge:

No delusions or hallucinations noted. Speech coherent. Client has a well-groomed appearance. Individual therapy attended daily.

Medication Administration Record Haloperidol 3 mg PO twice daily

The nurse is providing discharge teaching to the client. Which of the following information should the nurse include when educating the client about relapse prevention? Select all that apply.

Take a dose of the medication as soon as delusions or hallucinations begin.

Report any adverse effects of the medication to the provider immediately.

Notify your provider within 48 hr of manifestations of a relapse.

Go for a walk to decrease anxiety during times of increased stress.

Ask a trusted person to watch for manifestations of illness.

Limit alcohol consumption to no more than two drinks per week.

Answer and Explanation

Correct Answer : B,C,D,E

B is correct because reporting any adverse effects of the medication can help the provider adjust the dosage or prescribe a different medication if needed. Some common adverse effects of haloperidol are extrapyramidal symptoms, tardive dyskinesia, neuroleptic malignant syndrome, and anticholinergic effects.

C is correct because notifying the provider within 48 hr of manifestations of a relapse can help the client receive timely intervention and prevent further deterioration of their mental health. Some signs of a relapse are increased anxiety, paranoia, social withdrawal, insomnia, and mood swings.

D is correct because going for a walk or engaging in other physical activities can help the client cope with stress and reduce anxiety, which are common triggers for schizophrenia symptoms.

E is correct because asking a trusted person to watch for manifestations of illness can help the client gain insight into their condition and seek help when needed. A trusted person can be a family member, a friend, or a mental health professional.

A is incorrect because taking a dose of the medication as soon as delusions or hallucinations begin is not an effective strategy for relapse prevention. The client should take their medication as prescribed by their provider and not adjust the dosage on their own.

F is incorrect because limiting alcohol consumption to no more than two drinks per week is not sufficient for relapse prevention. Alcohol can interact with haloperidol and increase its sedative effects, impairing the client's judgment and cognition. Alcohol can also worsen schizophrenia symptoms and interfere with recovery. The client should avoid alcohol altogether or consult with their provider before consuming any alcohol.

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Correct Answer is B

Explanation

Delirium is an acute confusional state that can have various causes, such as infection, medication, or metabolic imbalance. It is characterized by a sudden onset of altered mental status, fluctuating levels of consciousness, disorientation, and perceptual disturbances.

A. WBC count 13,000/mm B. Neuropathy C. BUN 16 mg/dL D. Hypertension

Correct Answer is A

Explanation

A WBC count of 13,000/mm indicates infection, which is a common cause of delirium in older adults. Delirium is an acute confusional state that can result from various factors, such as medications, metabolic disturbances, sensory impairment, or environmental changes. Neuropathy, BUN 16 mg/dL, and hypertension are chronic conditions that do not directly cause delirium, although they may contribute to the client's overall health status.

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is restless and constantly mutters to himself. Which of the following findings should lead the nurse to suspect delirium?

Correct Answer is B

Explanation

A nurse in a long-term care facility is caring for a client. The nurse should identify that which of the following conditions places the client at an increased risk for developing delirium?

Correct Answer is A

Explanation

A nurse on a mental health unit placed a client in mechanical restraints after the client assaulted another client. Which of the following actions should the nurse take?

A nurse is conducting an admission interview with a new client who tells the nurse, "My life is so stressful. I can't take it anymore." Which of the following responses should the nurse make first?

A nurse is receiving change-of-shift report for four clients. Which of the following clients should the nurse see first?

A home health nurse is caring for a client who is in the continuation phase of major depressive disorder. The client states, "I feel unmotivated and don't feel like leaving my home." Which of the following recommendations should the nurse make to address the client's social isolation?

A nurse is caring for a client whose partner died 6 months ago. Which of the following findings is the nurse's priority?

A nurse is leading a critical incident stress debriefing with a group of staff members following a mass trauma incident. Which of the following interventions should the nurse take first?

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