A nurse is caring for a client who has schizophrenia.
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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Stimulants: While stimulants can cause symptoms such as increased energy, agitation, and paranoia, the specific combination of paranoia, visual disturbances (such as talking to the wall), and altered perception is more indicative of hallucinogen use.
B. Anabolic steroids: Anabolic steroids primarily affect physical strength and body composition, and while they can lead to aggressive behavior, they do not typically cause the acute symptoms of paranoia and visual hallucinations seen in this client.
C. Hallucinogens: The symptoms described, including paranoia, dizziness, vomiting, and visual disturbances (evidenced by the client talking to the wall), are characteristic of hallucinogen use. Hallucinogens can induce altered perceptions and significant changes in mood and thought processes, leading to behaviors like the ones exhibited by the client.
D. Opioids: Opioids generally cause sedation, respiratory depression, and a sense of euphoria, but they do not typically produce paranoia or hallucinations. The symptoms presented by the client do not align with opioid intoxication.
Correct Answer is D
Explanation
A. The nurse will lose their nursing license immediately: While stealing and taking drugs from the narcotics cart is a serious offense, losing a nursing license typically involves a formal investigation process and a hearing before the board of nursing. Immediate revocation is unlikely without due process.
B. The nurse will need to transfer to a different unit: Transferring to a different unit does not address the underlying issue of substance abuse or theft. While this may occur in some cases, it is not a likely initial outcome given the severity of the allegations.
C. The nurse will be fired immediately: While termination may occur as a consequence of the behavior, it is not the immediate action taken in response to the report. The facility may conduct an investigation before deciding on termination.
D. The nurse will be assisted into drug treatment: It is common for healthcare facilities to offer assistance for substance use disorders, especially if the nurse expresses a willingness to seek help. The initial outcome often includes referrals to treatment programs as part of a broader approach to address the issue and ensure the nurse receives the necessary support.
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