A patient diagnosed with schizophrenia may demonstrate these positive symptoms (select all that apply) :

Answering questions with nonsensical phrases.

Seeing, hearing, or feeling something that is not really there.

The feeling that external events such as the weather forecast or news story have special meaning for the patient.

Trouble staying on a schedule or finishing what the patient starts.

Inability to socially connect with others.

Answer and Explanation

Correct Answer : A,B,C

Choice A reason : Answering questions with nonsensical phrases is a positive symptom of schizophrenia. It reflects disorganized thinking and speech, which can manifest as incoherence or irrelevance in the patient's verbal communication². This symptom can significantly impair the patient's ability to engage in meaningful conversation and is often one of the more noticeable signs of schizophrenia during an assessment³.

Choice B reason : Seeing, hearing, or feeling something that is not really there, also known as hallucinations, are hallmark positive symptoms of schizophrenia. These sensory experiences occur without an external stimulus and can involve any of the senses, although auditory hallucinations are the most common in schizophrenia². Hallucinations can be extremely distressing for patients and can lead to difficulties in distinguishing reality from delusion³.

Choice C reason : The belief that personal significance is attached to trivial or unrelated external events, known as delusions of reference, is another positive symptom of schizophrenia. Patients may believe that messages are being sent to them through the television, radio, or other public means². This can lead to a profound sense of misunderstanding and isolation as the patient navigates a world they perceive as filled with hidden messages meant specifically for them³.

Choice D reason : While trouble staying on a schedule or finishing tasks can be associated with schizophrenia, it is not considered a positive symptom. These issues are more reflective of the negative symptoms of schizophrenia, which include avolition or the lack of motivation to initiate and complete goal-directed activities⁴.

Choice E reason : An inability to socially connect with others is also not a positive symptom but rather a negative symptom of schizophrenia. Negative symptoms represent a loss or a decrease in the ability to initiate plans, speak, express emotion, or find pleasure in everyday life⁴. Social withdrawal and impaired social interaction are common negative symptoms that can be mistaken for introversion or depression³.

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Correct Answer is A

Explanation

Choice A reason : The immediate safety of the client is the nurse's primary concern. Assessing the risk for immediate harm is crucial to prevent further abuse and to ensure the client's well-being. This involves evaluating the severity of the situation and the potential for future harm¹.

Choice B reason : While referring the client to a community support group is important for long-term support, it is not the immediate priority when a client reports abuse.

Choice C reason : Implementing a safety plan is a critical step, but it follows the initial assessment of immediate risk. The safety plan will be part of the ongoing support and intervention for the client.

Choice D reason : Instructing the client on how to leave the relationship is an important aspect of empowering the client; however, it is not the first action to take before assessing immediate risk and ensuring the client's safety.

A. Delegate the NG tube placement to a more experienced nurse. B. Make a referral to Social Services related to body image disturbance. C. Seek the client's spouse for consent to the procedure. D. Document the client's wishes and notify the physician.

Correct Answer is D

Explanation

Choice A reason : Delegating the NG tube placement to a more experienced nurse does not address the client's refusal of the procedure. The nurse must respect the client's autonomy and decision-making rights.

Choice B reason : While a referral to Social Services may be appropriate in some cases, it does not directly address the immediate concern of the client's refusal of the NG tube placement.

Choice C reason : Seeking consent from the client's spouse is not appropriate as the client is competent and has the right to refuse treatment. The client's autonomy must be respected.

Choice D reason : Documenting the client's wishes and notifying the physician is the correct action. The nurse must respect the client's right to refuse treatment and communicate this decision to the physician so that alternative management can be considered.

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A patient diagnosed with schizophrenia may demonstrate these positive symptoms (select all that apply) :

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has reported experiencing abuse at home. Which of the following actions should be a priority for the nurse?

Correct Answer is A

Explanation

Correct Answer is D

Explanation

A nurse is caring for a client who has schizophrenia and is experiencing a hallucination. Which of the following actions should the nurse take?

A patient diagnosed with schizophrenia may demonstrate these positive symptoms (select all that apply) :

A nurse in a clinic is caring for a client who has recently begun taking warfarin. The nurse is reviewing potential drug and food interaction risks and should instruct the client to avoid which of the following?

A nurse is planning care for a client who has cirrhosis and ascites. Which of the following interventions should the nurse include in the plan of care?

A nurse is caring for a client who is experiencing manifestations of alcohol withdrawal. Which of the following medications should the nurse anticipate the provider to prescribe?

A nurse is caring for a client with left-sided heart failure. To reduce fluid volume excess, which of the following should the nurse anticipate using?

A nurse is providing teaching for a client who has a new diagnosis of angina pectoris. Which of the following information should the nurse include about anginal pain?

A nurse is caring for a client who has been diagnosed with obsessive-compulsive disorder (OCD) and is constantly picking up after others in the day room. The nurse should recognize that the client uses this behavior to do which of the following?