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 C

Explanation

Choice A reason: Showing the client how to clean assumes cognitive capacity impaired in schizophrenia, where psychosis or disorganized thinking drives behaviors like fecal smearing. This may reflect delusions, not a lack of cleaning knowledge. Escorting the client out prioritizes hygiene and safety, allowing psychiatric assessment over teaching in an acute situation.

Choice B reason: Assisting with cleaning risks reinforcing the behavior and exposes both to pathogens like E. coli in feces. Schizophrenia may impair compliance or understanding. Escorting the client out ensures safety and hygiene, enabling evaluation of psychotic triggers, making this less appropriate than removing the client from the situation.

Choice C reason: Escorting the client out prevents further pathogen exposure, as feces carry infection risks (e.g., gastroenteritis). In schizophrenia, smearing may stem from psychosis, requiring psychiatric evaluation. This action ensures hygiene and safety, allowing assessment of underlying mental health issues, addressing the behavior’s root cause effectively.

Choice D reason: Explaining that feces belong in the toilet assumes rational understanding, impaired in schizophrenia due to disorganized thought or delusions. This behavior likely reflects psychosis. Escorting the client out prioritizes hygiene and safety, followed by psychiatric intervention, making explanation less effective than immediate removal from the contaminated area.

A. Cut the nails straight across, then soak the feet for 10 minutes in an antibiotic solution. B. Check the client’s feet for cuts or injury, then refer to a foot specialist for nail trimming. C. Soak the feet in warm water for 5 minutes, then cut the nails straight across. D. Advise the client to soften the nails with lotion prior to cutting them.

Correct Answer is B

Explanation

Choice A reason: Cutting nails and soaking in antibiotic solution risks infection in insulin-dependent diabetes, where neuropathy impairs sensation and healing. Thick nails may be fungal, needing specialist care. Checking for injuries and referring to a podiatrist ensures safe management, preventing ulcers in high-risk diabetic feet.

Choice B reason: Checking for cuts assesses diabetic foot risk, as neuropathy and poor glycemic control impair healing. Thick nails piercing toes require podiatrist trimming to prevent trauma or infection. Referral ensures expert care, addressing pathophysiological risks of neuropathy and vascular impairment, preventing serious complications like ulcers.

Choice C reason: Soaking and cutting nails is risky in diabetes, as neuropathy increases injury risk, and warm water may introduce infection in unnoticed wounds. Fungal nails need specialist care. Referral to a podiatrist ensures safe trimming, preventing infection in compromised feet, making this action unsafe.

Choice D reason: Advising lotion to soften nails does not mitigate injury risk from trimming thick nails in diabetes. Neuropathy and poor healing increase infection risk from errors. Specialist referral ensures safe nail management, preventing trauma or ulceration, critical in diabetic foot care due to vascular deficits.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older adult male client with schizophrenia is found smearing feces on the bathroom walls of the chronic mental health unit where he resides. Which action should the nurse implement?

Correct Answer is C

Explanation

An older adult client, who is insulin-dependent, arrives at the diabetic clinic with concerns of thick, crusty, and long toenails that are piercing the adjacent toes. Which action should the nurse take?

Correct Answer is B

Explanation

A client is admitted to the hospital with symptoms consistent with a right hemisphere stroke. Which neurovascular assessment requires immediate intervention by the nurse?

Following admission for a cardiac catheterization, the nurse is providing discharge teaching to the parents of a 2-year-old toddler with Tetralogy of Fallot. Which instruction should the nurse give the parents if their child becomes pale, cool, and lethargic?

Which serum laboratory test is most important for the nurse to monitor when administering enoxaparin to a client?

Which instruction should the nurse include in the discharge teaching plan of a client who is prescribed ibuprofen for arthritic pain?

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?

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?

The nurse is changing a client’s abdominal surgical dressing. Which finding warrants notification to the healthcare provider?