A nurse is caring for a client who has schizophrenia and notices changes in the client’s behavior.
Which of the following behaviors is the nurse’s priority to report to the provider?
Meaningless phrases
Refusal to eat
Substance use
Decreased energy level
The Correct Answer is A
Choice A rationale:
Meaningless phrases are a hallmark symptom of schizophrenia and can indicate a worsening of the client's psychosis. This is a significant finding because it suggests that the client's ability to think clearly and communicate effectively is deteriorating.
Prompt reporting to the provider is crucial to ensure timely assessment and intervention, which may include medication adjustments or other therapeutic measures to address the worsening psychosis.
Early intervention is essential to prevent further decline in the client's mental state and to minimize the risk of harm to self or others.
I'll provide detailed rationales for the other choices, even though they are not the priority to report:
Choice B rationale:
Refusal to eat can be a symptom of schizophrenia, but it is not as immediate of a concern as meaningless phrases. It's important to monitor the client's nutritional intake and address any underlying causes of the refusal to eat, but this can typically be managed through nursing interventions without requiring immediate provider notification.
Choice C rationale:
Substance use can exacerbate schizophrenia symptoms and should be addressed, but it is not the priority to report in this scenario. The nurse should assess the client's substance use history and patterns, provide education and counseling on the risks of substance use, and collaborate with the provider to develop a treatment plan that addresses both the schizophrenia and the substance use.
Choice D rationale:
Decreased energy level can be a symptom of schizophrenia, but it is also a common symptom of many other conditions. It's important to assess the client's overall health and identify any potential causes of the decreased energy level, but it is not typically a priority to report to the provider unless it is severe or accompanied by other concerning symptoms
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Psychomotor retardation is a characteristic of depression, not hypomania. In fact, individuals with hypomania typically exhibit psychomotor agitation, which is characterized by increased energy and activity levels.
Psychomotor retardation often manifests as slowed movements, speech, and thought processes. It can significantly impact an individual's ability to perform daily tasks and engage in social interactions.
While psychomotor retardation can occur in various mental health conditions, it is not typically associated with hypomania.
Choice B rationale:
Decreased self-esteem is also a characteristic of depression, not hypomania. Individuals with hypomania typically experience inflated self-esteem and grandiosity.
They may overestimate their abilities, make unrealistic plans, or engage in risky behaviors. This inflated sense of self-worth is often a hallmark feature of hypomania and can contribute to impaired judgment and decision-making.
Choice C rationale:
Euphoria is a hallmark symptom of hypomania. It is characterized by an elevated, expansive, or irritable mood that is persistent and noticeable to others.
Individuals with euphoria often feel excessively happy, cheerful, or optimistic. They may have increased energy, decreased need for sleep, and a heightened sense of well-being.
They may also be more talkative, outgoing, and engage in pleasurable activities more often.
This elevated mood is a core feature of hypomania and is often accompanied by other characteristic symptoms, such as increased activity levels, racing thoughts, and impulsivity.
Choice D rationale:
Hallucinations are not a typical feature of hypomania. They are more commonly associated with psychotic disorders, such as schizophrenia.
Hallucinations involve perceiving things that are not real, such as hearing voices or seeing things that are not there.
While hallucinations can occur in some individuals with hypomania, they are not a defining feature of the condition
Correct Answer is D
Explanation
A rationale:
Spending time with friends can be a protective factor against suicide, as it provides social support and connection.
While isolation can be a risk factor, spending time with friends does not inherently indicate suicide risk.
It's important to assess the quality of relationships and the presence of other risk factors.
Choice B rationale:
Regular sleep patterns often indicate healthy mental health.
Significant changes in sleep patterns (either too much or too little) can be warning signs, but consistent sleep of 9 hours is not typically a concern.
It's essential to evaluate sleep quality and any recent changes.
Choice C rationale:
Religious involvement can provide a sense of purpose, belonging, and support, which can be protective against suicide.
While it's not a guarantee of protection, it's generally a positive factor.
It's crucial to assess the individual's level of engagement and any potential conflicts within their religious beliefs.
Choice D rationale:
Exposure to suicide, especially in a close connection like a coach, can significantly increase a person's risk for suicide.
It can lead to normalization of suicide as a coping mechanism, imitation of behavior, or triggering of underlying mental health issues.
This is a strong risk factor that warrants immediate attention and assessment.
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