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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale:

Maternal hemoglobin and hematocrit levels are important indicators of the mother's health but are not direct indicators of fetal well-being.

Choice B rationale:

A Coombs test is performed on newborns to assess for hemolytic disease, not to monitor fetal well-being.

Choice C rationale:

A biophysical profile assesses multiple parameters of fetal well-being, including fetal heart rate, fetal movement, fetal breathing, amniotic fluid volume, and fetal tone.

Choice D rationale:

An alpha-fetoprotein test is a screening test for neural tube defects and chromosomal abnormalities but is not typically used to monitor fetal well-being in hypertensive pregnancies.

A. Monitor the client's blood pressure daily. B. Allow the client to exercise once per week. C. Encourage the client to participate in group activities. D. Provide the client with high-calorie finger foods.

Correct Answer is D

Explanation

Choice A rationale:

This is not a priority intervention for a client who is in the manic phase of bipolar disorder. The nurse should monitor the client's vital signs as indicated, but blood pressure is not likely to be affected by mania unless the client has a preexisting condition or is taking medications that affect blood pressure.

Choice B rationale:

This is not an appropriate intervention for a client who is in the manic phase of bipolar disorder. The nurse should not restrict the client's physical activity, as this can increase their frustration and agitation. The nurse should provide a safe environment for the client to expend their energy and channel it into productive activities.

Choice C rationale:

This is not a suitable intervention for a client who is in the manic phase of bipolar disorder. The nurse should avoid stimulating the client's already elevated mood and arousal, as this can worsen their symptoms and increase their risk of injury or aggression. The nurse should limit the client's exposure to noise, crowds, and bright lights, and provide them with opportunities for rest and quiet time.

Choice D rationale:

A client who is in the manic phase of bipolar disorder has increased energy, activity, and metabolism, which can lead to weight loss and nutritional deficiencies. The nurse should provide the client with high-calorie finger foods that are easy to eat and do not require utensils or sitting down. This way, the nurse can help the client meet their nutritional needs while respecting their need for movement and autonomy.

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A nurse is caring for a newly admitted client who has schizophrenia. Which of the following actions is the nurse's priority?

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Naxlex Comprehensive Predictor Exams

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