A nurse on an in-patient unit received the report at 15:00 hours. Which client should the nurse see first?

A Client diagnosed with hypomania who is speaking loudly on the unit

A client diagnosed with mania who expressed active suicidal ideations

A client with a history of mania who is pacing in the hallway

A client diagnosed with hypomania who is complaining of pain

Answer and Explanation

The Correct Answer is B

Client diagnosed with hypomania who is speaking loudly on the unit: While hypomanic individuals may exhibit increased energy and talkativeness, the urgency is lower compared to a client expressing active suicidal ideations. This client does not pose an immediate threat to themselves or others.

B. Client diagnosed with mania who expressed active suicidal ideations: This is the correct answer. A client with active suicidal ideations is at an elevated risk and requires immediate attention. Suicidal thoughts in the context of mania can be impulsive, and prompt intervention is crucial to ensure the client's safety.

C. Client with a history of mania who is pacing in the hallway: Pacing may be a symptom of mania, but without additional information about the client's current state and any potential immediate risks, the client expressing active suicidal ideations takes precedence.

D. Client diagnosed with hypomania who is complaining of pain: Pain complaints, in the absence of other urgent factors, do not take precedence over active suicidal ideations. The risk of harm to oneself or others is a higher priority.

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Correct Answer is B

Explanation

A. Use touch to calm the client during periods of anxiety:

Individuals with paranoid schizophrenia may have heightened sensitivity to touch, and it can potentially exacerbate their anxiety or paranoia. This intervention may not be appropriate as it could escalate the client's distress.

B. Check the client's mouth after the client takes medication:

This is the best choice. People with paranoid schizophrenia may be prone to hoarding or pocketing medications. Checking the client's mouth ensures that the medication has been swallowed, promoting medication adherence and preventing potential harm.

C. Rotate the staff assignments for this client:

Consistency in caregivers is generally preferred for clients with schizophrenia to build trust and a therapeutic relationship. Constantly changing staff assignments can lead to increased anxiety and mistrust.

D. Assign an assistive personnel to feed the client at meal times:

While assistance with feeding may be needed, assigning an assistive personnel without direct supervision for a client with paranoid schizophrenia may not be the best approach. It's important to ensure the client's safety and monitor their behavior during meals.

A. WBC count 3.300/mm B. Asthma C. Hypertension D. Fasting blood glucose 120 mg/dl

Correct Answer is A

Explanation

A. WBC count 3,300/mm³.

Clozapine, an atypical antipsychotic medication, is associated with a risk of agranulocytosis, which is a severe reduction in white blood cell (WBC) count. A WBC count of 3,300/mm³ is significantly below the normal range, and it indicates a contraindication to the use of clozapine.

B. Asthma:

Asthma is not a contraindication to clozapine. However, it is important to monitor respiratory function as antipsychotic medications can have side effects related to respiratory function.

C. Hypertension:

Hypertension alone is not a contraindication to clozapine. Clozapine can, however, be associated with some cardiovascular side effects, so blood pressure should be monitored regularly.

D. Fasting blood glucose 120 mg/dL:

An elevated fasting blood glucose level is not a contraindication to clozapine. However, it is important to monitor metabolic parameters as antipsychotic medications, including clozapine, can be associated with metabolic side effects.

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A nurse on an in-patient unit received the report at 15:00 hours. Which client should the nurse see first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has paranoid schizophrenia. Which of the following interventions should be included in the plan of care?

Correct Answer is B

Explanation

A nurse is reviewing the medical record of a client who has a new prescription for clozapine for the treatment of schizophrenia. Which of the following findings indicates a contraindication to clozapine?

Correct Answer is A

Explanation

A client is diagnosed with schizophrenia. A physician orders haloperidol (Haldol), 50 mg bid: benztropine (Cogentin), 1 mg prn: and zolpidem (Ambien). 10 mg HS. Which client behavior would warrant the nurse to administer benztropine?

A nurse is discussing bias issues in mental health with a newly licensed nurse. Which of the following statements should the nurse include in the discussion?

Which nursing diagnosis should be prioritized when providing care to a client diagnosed with paranoid personality disorder?

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A nurse learns at report that a newly admitted client experiencing mania is demonstrating grandiose delusions. The nurse should recognize which client statement would provide supportive evidence of this symptom?

A nurse is completing an assessment of a client. Which of the following information should the nurse anticipate the provider will use in the diagnosis of a mental health disorder?

A nurse is caring for a client who has schizophrenia and tells the nurse. "They lie about me all the time and they are trying to poison my food." Which of the following statements should the nurse make?