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?

Show the client how to clean the walls.

Assist the client to clean the walls.

Escort the client out of the bathroom.

Explain that feces belong in the toilet.

Answer and Explanation

The Correct Answer is C

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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A reason: Avolition in schizophrenia is lack of motivation for goal-directed tasks, linked to prefrontal dopamine deficits. Performing activities of daily living (e.g., hygiene) shows improved motivation, achieving the goal. This reflects enhanced frontal lobe function, addressing the negative symptom of avolition, critical for functional recovery in schizophrenia.

Choice B reason: Explaining answers to open-ended questions shows cognitive ability, not motivation. Avolition impairs initiative for tasks like self-care, not verbal skills. Schizophrenia’s negative symptoms reduce drive, and this behavior does not address the motivational deficit targeted, making it less relevant than performing daily activities.

Choice C reason: Reporting enjoyment suggests improved affect but not motivation. Avolition involves initiating tasks, not emotional response. Performing daily activities directly demonstrates overcoming avolition, a negative symptom of reduced drive, aligning with the goal of enhancing goal-directed behavior in schizophrenia, making this less indicative.

Choice D reason: Sharing a story indicates social engagement, impaired in schizophrenia but not specific to avolition, which affects motivation for routine tasks. Performing daily activities directly shows improved initiative, addressing the treatment goal’s focus on overcoming dopamine-related motivational deficits, making social sharing less relevant.

A. Denies muscle spasms in extremities. B. Complains of back and joint tenderness and pain. C. Complains of muscle twitching in hands and feet. D. Diaphoretic, but denies any headache.

Correct Answer is C

Explanation

Choice A reason: Denying muscle spasms is normal and not a complication. Muscle twitching indicates hypocalcemia, a thyroidectomy risk due to parathyroid damage. Absence of spasms is reassuring, per postoperative complication monitoring and endocrine surgical care standards in nursing.

Choice B reason: Back and joint pain are nonspecific and not typical thyroidectomy complications. Muscle twitching suggests hypocalcemia, a critical issue post-thyroidectomy. Pain requires assessment but is less urgent, per postoperative monitoring and complication management protocols in surgical nursing.

Choice C reason: Muscle twitching in hands and feet indicates hypocalcemia, a serious complication from parathyroid gland damage during thyroidectomy. This requires immediate calcium replacement to prevent tetany, per postoperative complication monitoring and endocrine surgical care protocols in nursing practice.

Choice D reason: Diaphoresis without headache is nonspecific and not a primary thyroidectomy complication. Muscle twitching signals hypocalcemia, needing urgent intervention. Diaphoresis requires monitoring but is less critical, per postoperative assessment and complication management standards in surgical nursing.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The mental health team working with a homeless client with chronic schizophrenia establishes the treatment goal of, “Improvement in avolition prior to discharge.” Which behavior demonstrates achievement of this goal to the nurse?

Correct Answer is A

Explanation

Following a total thyroidectomy, the nurse plans to observe a client for complications. Which finding indicates that the client has developed a complication?

Correct Answer is C

Explanation

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

A primigravida at 40 weeks gestation is contracting every 2 minutes, and her cervix is 9 cm dilated and 100% effaced. The fetal heart rate is 120 beats/minute. The client is screaming and her husband is alarmed. Which intervention should the nurse implement?

Which client information indicates the need for the nurse to use the CAGE questionnaire during the admission interview?

The nurse orients a client with depression to a new room on the mental health unit. The client states, “It seems strange that I don’t have a television (TV) in my room.” Which statement is best for the nurse to provide?

A client newly diagnosed with eczema tells the clinic nurse of using a heat lamp to dry the fluid-filled blisters localized in the left antecubital area. How should the nurse respond?

The nurse is developing a teaching plan for a client with peripheral arterial disease (PAD) who has a history of myocardial infarction (MI) and smokes two packs of cigarettes daily. Which instruction has the highest priority?

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?