A nurse is caring for a newly admitted client who has schizophrenia. Which of the following actions is the nurse's priority?
Determine if the client is experiencing command hallucinations.
Arrange for the client to have consistent staff assignments.
Administer lorazepam to the client.
Use the client's name when talking to him.
The Correct Answer is A
Choice A rationale:
Assessing for the presence of command hallucinations is a priority, as they can pose a risk to the client's safety and the safety of others.
Choice B rationale:
Consistent staff assignments can be important for clients with schizophrenia, but immediate safety concerns should take precedence.
Choice C rationale:
Administering medication is not the priority action unless there is a specific reason to do so based on the assessment.
Choice D rationale:
Using the client's name is respectful and helpful, but it is not the priority action in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E"]
Explanation
Choice A rationale:
Agitation is a common manifestation of delirium, as the client experiences a disturbance in attention, awareness, and cognition. The client may become restless, irritable, or aggressive due to the altered mental state.
Choice B rationale:
Slow, flat speech is not a manifestation of delirium, but rather a sign of depression or dementia. Clients with delirium may have rapid, incoherent, or slurred speech, depending on the cause and severity of the condition.
Choice C rationale:
Visual hallucinations are another manifestation of delirium, as the client may perceive things that are not there or misinterpret sensory stimuli. The client may also have auditory or tactile hallucinations, which can contribute to the agitation and confusion.
Choice D rationale:
Confusion is a hallmark manifestation of delirium, as the client has difficulty with orientation, memory, and reasoning. The client may not recognize familiar people or places, or may have fluctuating levels of consciousness. The confusion may worsen at night or in low-light settings, which is known as sundowning syndrome.
Choice E rationale:
Rapid mood swings are also a manifestation of delirium, as the client may exhibit emotional lability, anxiety, depression, fear, or anger. The mood changes may be unpredictable and inappropriate to the situation.
Correct Answer is A
Explanation
Choice A rationale:
Infants with osteogenesis imperfecta have fragile bones that can fracture easily. Using pillows or other soft support can help prevent accidental fractures during diaper changes.
Choice B rationale:
Immunizations are important for all infants and should not be withheld, even in the presence of osteogenesis imperfecta.
Choice C rationale:
Blood pressure measurement is not a common concern in infants with osteogenesis imperfecta.
Choice D rationale:
Splints may be used to provide support for the infant's limbs to minimize the risk of fractures.
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