An adult male who is admitted to the mental health clinic is alert and oriented to person, place, time, and situation. His affect is blunted, his mood dysphoric, and the nurse identifies his responses as tangential with a paranoid theme when he states, “I have a chip inside my head that is speaking to me.” Based on these assessment findings, which nursing problem is best to include in this client’s initial plan of care?

Disturbed thought process related to paranoid ideation.

Disturbed sensory perception related to grandiose self-beliefs.

Impaired verbal communications related to psychosis.

Impaired social interaction related to unrealistic thought processes.

Answer and Explanation

The Correct Answer is A

Choice A reason: The client’s belief in a chip in his head indicates paranoid ideation, a disturbed thought process in schizophrenia, driven by dopamine dysregulation in the mesolimbic pathway. This nursing problem targets altered reality perception, guiding antipsychotic therapy to reduce delusions, addressing the core cognitive disturbance observed.

Choice B reason: Disturbed sensory perception implies hallucinations, not delusions. The chip belief is a paranoid delusion, not a sensory issue or grandiose belief. Schizophrenia involves cognitive distortions, and “disturbed thought process” better addresses the paranoid ideation, focusing on the neurobiological basis of delusional thinking over sensory misperceptions.

Choice C reason: Impaired verbal communication is inaccurate, as the client is alert and oriented with coherent, though tangential, speech. The chip delusion reflects a thought disorder, not communication deficit. Schizophrenia’s cognitive symptoms prioritize addressing thought processes, driven by neurotransmitter imbalances, over verbal expression issues.

Choice D reason: Impaired social interaction may result from paranoid delusions but is secondary. The primary issue is the disturbed thought process causing the chip delusion, rooted in dopamine dysregulation. Addressing the delusion directly with antipsychotics is more specific, as social issues stem from this core cognitive disturbance.

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Correct Answer is A

Explanation

Choice A reason: Acetaminophen is hepatotoxic, metabolized by the liver via cytochrome P450 to NAPQI, which depletes glutathione, causing necrosis in hepatitis. A compromised liver from alcohol or viral hepatitis increases toxicity risk, even at standard doses. Contacting the provider ensures safer analgesics, preventing further liver damage in this high-risk client.

Choice B reason: Olanzapine, an antipsychotic, manages schizophrenia by blocking dopamine D2 receptors. It is metabolized by the liver but has low hepatotoxicity risk compared to acetaminophen in hepatitis. No immediate contraindication exists, as it controls psychosis without significantly worsening liver function, making it safe to administer without delay.

Choice C reason: Thiamine (vitamin B1) is essential in hepatitis, particularly with alcohol abuse, preventing Wernicke’s encephalopathy from deficient glucose metabolism. It is liver-safe and beneficial, supporting neurological function without toxicity. Administering thiamine is appropriate, making it unnecessary to contact the provider before implementation.

Choice D reason: Ondansetron, an antiemetic, controls nausea in hepatitis via serotonin 5-HT3 receptor blockade. It is metabolized by the liver but has minimal hepatotoxicity, safe in liver disease. No contraindication exists, as it alleviates symptoms without worsening hepatitis, unlike acetaminophen, which poses significant liver risk.

A. Discourage straining on stool. B. Medicate with PRN IV narcotic. C. Initiate infusion for an IV fluid bolus. D. Administer an IV antiemetic.

Correct Answer is B

Explanation

Choice A reason: Discouraging straining on stool prevents pain exacerbation or constipation in cancer but is not the priority with a pain score of 9. Severe pain from bone metastases, stimulating nociceptors, requires urgent IV narcotics to improve comfort, addressing the primary palliative goal over secondary issues like straining.

Choice B reason: A pain score of 9 in metastatic bone cancer indicates severe nociceptive pain from tumor invasion. IV narcotics (e.g., morphine) rapidly bind opioid receptors, reducing pain perception. This prioritizes comfort in palliative care, especially with stable vitals (SpO₂ 95%), addressing pain before nausea in this critical scenario.

Choice C reason: An IV fluid bolus treats dehydration from vomiting but does not address severe pain (9/10), a palliative priority. Bone metastases cause intense pain, requiring narcotics. Fluids are secondary, as vitals (BP 110/80) suggest stability, making pain relief more urgent to enhance quality of life in palliative care.

Choice D reason: An IV antiemetic controls nausea, likely from tumor or treatment effects, but severe pain (9/10) is the priority in palliative care. Narcotics provide rapid relief for bone metastasis pain, improving comfort. Antiemetics are secondary, as pain significantly impacts quality of life more immediately than nausea.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a history of schizophrenia, and drug and alcohol abuse is admitted to the hospital for hepatitis. The nurse should contact the healthcare provider before implementing which prescription?

Correct Answer is A

Explanation

Correct Answer is B

Explanation

After placing a client who is having a seizure in the side-lying position, which intervention should the nurse implement?

After suctioning a client who has an endotracheal tube, which assessment finding indicates to the nurse that the intervention was effective?

Which nursing intervention is most effective in determining the severity of a client’s pain?

After a client voids, 150 mL of residual urine is measured. Which nursing problem should be included in this client’s plan of care?

The nurse is caring for a client with a new tracheostomy. Which action is most important to include in the client’s plan of care?

Following a ureterolithotomy, the client has a ureteral catheter in place. Which intervention should the nurse implement?

A client has begun a long-term maintenance therapy with lithium, which has a narrow therapeutic index. Which adverse effect is most important for the nurse to include in the teaching plan?