A nurse on a mental health unit is assisting with the care of a client.
The nurse is continuing to assist with the care of the client. Select the four actions the nurse should take.
Ask the provider for a PRN prescription for restraints.
Administer diazepam when the client exhibits anxiousness.
Place the client in a room near the nurse's station.
Determine if the client is experiencing command hallucinations.
Establish clear limits for expected behaviors.
Correct Answer : B,C,D,E
A. Ask the provider for a PRN prescription for restraints: Restraints should only be used as a last resort when there is an imminent risk of harm to the client or others. In this situation, it is essential to first attempt to manage the client's anxiety and behavior through de-escalation strategies and appropriate interventions.
B. Administer diazepam when the client exhibits anxiousness: Diazepam can help manage anxiety and agitation, which is crucial for the client's safety and comfort. Monitoring for signs of anxiety allows for timely intervention with the prescribed medication.
C. Place the client in a room near the nurse's station: Keeping the client close to the nurse's station allows for increased monitoring and ensures that staff can respond quickly if the client's behavior escalates. This helps maintain safety for both the client and others on the unit.
D. Determine if the client is experiencing command hallucinations: Assessing for command hallucinations is important, especially given the client's recent aggressive behavior. Understanding the presence of such hallucinations can guide the treatment plan and safety measures.
E. Establish clear limits for expected behaviors: Setting clear expectations for behavior helps the client understand acceptable conduct and promotes a safer environment. This can be particularly important for clients with paranoid personality disorder who may struggle with interpersonal relationships.
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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 A
Explanation
A. Symptoms of major depression or mania: Schizoaffective disorder is characterized by the presence of mood disorder symptoms (such as major depression or mania) in conjunction with symptoms of schizophrenia, including delusions or hallucinations. During the active phase of schizoaffective disorder, individuals experience both psychotic symptoms and significant mood disturbances.
B. Absence of delusions or hallucinations: In schizoaffective disorder, delusions and hallucinations are present alongside mood symptoms. Therefore, the absence of these psychotic symptoms does not characterize the active phase.
C. More severe negative symptoms: While schizoaffective disorder can have negative symptoms, such as emotional flattening or lack of motivation, the emphasis is more on the co-occurrence of mood symptoms rather than solely on negative symptoms.
D. Anosognosia is more severe: Anosognosia refers to a lack of awareness of one's own illness. While it can occur in both schizophrenia and schizoaffective disorder, the severity of anosognosia is not a distinguishing factor specifically associated with the active phase of schizoaffective disorder.
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