A nurse is caring for a client who has schizophrenia.

Exhibits

The nurse is reviewing the client's medical record.

Select the "3" findings that require immediate follow-up by the nurse.

Blood pressure

Hallucinations

Insomnia

Delusions

Appetite

Answer and Explanation

Correct Answer : A,B,C

A. Blood pressure: The client's blood pressure has increased significantly from 132/68 mm Hg to 156/92 mm Hg. This elevation may indicate a physiological response to anxiety or agitation and requires monitoring and assessment for potential cardiovascular issues.
B. Hallucinations: The client reports auditory hallucinations ("the voices are coming back") and visual hallucinations (seeing a man in the corner of the room). These symptoms indicate a need for immediate intervention and further evaluation to ensure the client's safety and address their psychotic symptoms.
C. Insomnia: The client states they cannot sleep, which is a significant concern as lack of sleep can exacerbate psychiatric symptoms, impair functioning, and increase the risk of self-harm or harm to others. Addressing sleep disturbances is critical for the client's overall treatment and well-being.
D. Delusions: While delusions (e.g., believing that people are trying to hurt the client) are concerning and require monitoring, the hallucinations reported by the client are more acute and pose a more immediate risk to the client's safety. Therefore, hallucinations take priority over delusions in this situation.
E. Appetite: The client consumed 50% of their evening meal, which indicates some level of appetite. Although changes in appetite can be relevant in the context of mental health, it is not as urgent as the other findings related to blood pressure, hallucinations, and insomnia, which directly impact the client's immediate safety and well-being.

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Correct Answer is A

Explanation

A. General anxiety disorder: General anxiety disorder (GAD) is commonly seen as a comorbidity with cluster B personality disorders, which include borderline, antisocial, histrionic, and narcissistic personality disorders. Individuals with these personality disorders may experience significant anxiety, particularly related to interpersonal relationships and emotional instability.
B. Schizophrenia: Schizophrenia is classified as a serious mental illness, but it is not typically considered a comorbidity of cluster B personality disorders. The symptomatology of schizophrenia is distinct from that of personality disorders.
C. Obsessive-compulsive disorder: While obsessive-compulsive disorder (OCD) can occur alongside various mental health conditions, it is more commonly associated with cluster C personality disorders (e.g., obsessive-compulsive personality disorder) rather than cluster B.
D. Anorexia nervosa: Anorexia nervosa is an eating disorder that may co-occur with various mental health conditions, but it is not specifically recognized as a common comorbidity with cluster B personality disorders. The focus of cluster B disorders is more on interpersonal dynamics and emotional regulation rather than eating behaviors.

A. Initial use of substances began in adulthood. B. The developing brain is exposed to substances at an early age. C. The brain already has cognitive deficits that causes it to be vulnerable to addiction. D. Medical insurance availability for substance use disorder treatment.

Correct Answer is B

Explanation

A. Initial use of substances began in adulthood: Starting substance use in adulthood is generally associated with a lower risk of developing addiction compared to early initiation. Early exposure to substances can significantly affect brain development and increase vulnerability to addiction.
B. The developing brain is exposed to substances at an early age: Early exposure to substances during critical periods of brain development can disrupt normal neurological processes and increase the likelihood of developing substance use disorders later in life. This is a well-established risk factor for addiction.
C. The brain already has cognitive deficits that cause it to be vulnerable to addiction: While cognitive deficits can increase vulnerability to addiction, this factor is more specific and not as broadly applicable as the impact of early substance exposure on a developing brain.
D. Medical insurance availability for substance use disorder treatment: While having access to treatment is important for recovery, it does not increase the potential for addiction. In fact, access to treatment can help mitigate the effects of addiction and support recovery efforts.

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A nurse is caring for a client who has schizophrenia. Exhibits The nurse is reviewing the client's medical record. Select the "3" findings that require immediate follow-up by the nurse.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing education to a newly licensed nurse about comorbidities associated with cluster B personality disorders. The nurse should identify which of the following disorders as a comorbidity?

Correct Answer is A

Explanation

A nurse is educating a group of clients about addiction. The nurse should include that which of the following factors increases the potential for addiction?

Correct Answer is B

Explanation

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A nurse is providing information regarding the social determinants of mental health and persons with serious mental illnesses (SMI). Which of the following pieces of information should the nurse share during the presentation?

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A nurse is caring for a client who has avoidant personality disorder. Which of the following types of therapy should the nurse anticipate for the client?

A nurse is planning care for several clients. The nurse knows that which of the following findings are common in clients who have dependent personality disorder?

A nurse is assisting with planning care for a client who has been brought to the inpatient mental health unit by law enforcement officers after becoming aggressive in a local bar. The nurse should identify that this finding is consistent with which of the following disorders?

A nurse is caring for a client who has schizophrenia.

Exhibits

The nurse is reviewing the client's medical record.

Select the "3" findings that require immediate follow-up by the nurse.