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.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

Choice A reason: Comparing vital signs to baseline may show tachycardia from pain-induced sympathetic activation, but this is non-specific, as fever or anxiety can mimic these. Pain is subjective, involving nociceptor signaling, and the client’s direct intensity description provides the most accurate severity measure, guiding targeted treatment.

Choice B reason: Reviewing medical history provides pain context but not current severity. Pain perception involves spinal and cortical nociceptive pathways, and only the client’s description quantifies intensity. Historical data informs diagnosis, but direct assessment is more precise for evaluating present pain, ensuring appropriate analgesic intervention.

Choice C reason: Noting analgesic frequency suggests pain control needs but not current severity. Frequent dosing may indicate tolerance or inadequate relief, not intensity. Pain’s subjective nature, mediated by neural pathways, requires the client’s report to assess severity accurately, guiding dosing over indirect medication usage patterns.

Choice D reason: Asking the client to describe pain intensity directly captures their subjective experience, mediated by nociceptors and cortical perception. Using a 0–10 scale quantifies severity, guiding precise analgesia. This is most effective, as pain is personal, ensuring accurate assessment and tailored treatment to alleviate discomfort effectively.

A. “Your PCA pump has just been discontinued, and you need to wait at least one hour before leaving the unit.” B. “As long as you go to the smoking area in a wheelchair, it will be all right for you to go smoke.” C. “You may smoke in your room if you keep the door closed and open a window.” D. “Smoking is hazardous to your health, and since you just had surgery, it would be best for you to avoid smoking.”

Correct Answer is D

Explanation

Choice A reason: Delaying smoking for one hour is arbitrary and does not address smoking’s risks post-surgery. Nicotine causes vasoconstriction, reducing wound perfusion, and carbon monoxide impairs oxygen delivery, delaying healing. Advising against smoking mitigates these risks, promoting recovery, making this response less effective than cessation advice.

Choice B reason: Allowing smoking in a wheelchair ignores postoperative risks. Nicotine’s vasoconstriction reduces tissue oxygenation, and carbon monoxide lowers hemoglobin’s capacity, impairing healing. This increases infection or thrombosis risk. Advising against smoking addresses these physiological harms, prioritizing wound recovery over facilitating smoking, which is detrimental.

Choice C reason: Smoking in the room violates hospital safety and exposes others to secondhand smoke. Nicotine and carbon monoxide reduce tissue perfusion and oxygen delivery, delaying postoperative healing. Advising against smoking prevents these complications, ensuring better recovery, making this response unsafe and inappropriate for surgical patients.

Choice D reason: Advising against smoking is critical, as nicotine causes vasoconstriction, reducing blood flow to surgical sites, and carbon monoxide impairs oxygen delivery, delaying healing. These increase infection and thrombosis risks post-surgery. This response promotes optimal recovery, addressing physiological needs for wound healing in the critical 24-hour period.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is D

Explanation

When the nurse discontinues a 24-hour postoperative client’s patient-controlled analgesia (PCA) pump, the client asks to go to the hospital’s smoking area to smoke a cigarette. Which response should the nurse provide?

Correct Answer is D

Explanation

A client is admitted to the hospital with suicidal ideation. When completing the health history and admission assessment interview, which client comment is most important for the nurse to document?

An adolescent female arrives at the wellness clinic reporting fears that she will hurt herself. The nurse observes scars on both wrists of the client. Which priority action should the nurse implement?

A client with a history of atrial fibrillation is prescribed warfarin. The nurse notes the client’s INR is 4.8. Which action should the nurse take? Reference Range: INR [2.0 to 3.0 for atrial fibrillation].

The nurse is teaching a client with newly diagnosed glaucoma about the condition. Which statement by the client indicates a need for further teaching?

When advising a new mother in caring for a child with croup, which symptom should be a priority concern to the telephone triage nurse?

On the second postoperative day, a client reports increasing abdominal pain. Assessment findings include a distended abdomen with absent bowel sounds. Which intervention should the nurse anticipate implementing?

The nurse is assessing a client with a history of heart failure who reports new-onset dyspnea and fatigue. Which finding requires the most immediate intervention?

Which group of foods is best for the nurse to recommend for clients with a strong family history of colon and rectal cancers?