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.

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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. Place the client in a right lateral side-lying position and elevate the head of the bed. B. Compress the bulb with the tab open and then reinsert the tab into its opening. C. Irrigate the drain tubing with 1 mL of NS, then close the opening with its tab. D. Reinforce the incisional dressings and assess behind the neck for drainage.

Correct Answer is B

Explanation

Choice A reason: Positioning right lateral with head elevation may shift fluid but does not restore drain suction. Compressing the bulb creates negative pressure, promoting drainage. Positioning is less effective, per surgical drain management and postoperative care standards in nursing practice.

Choice B reason: Compressing the bulb with the tab open, then reinserting it, restores negative pressure, enhancing drainage in the surgical drain. This ensures fluid removal, preventing hematoma or infection, per evidence-based surgical drain management and postoperative care protocols in nursing practice.

Choice C reason: Irrigating the drain with saline risks infection and is not standard for low drainage. Compressing the bulb restores suction, promoting drainage safely. Irrigation is inappropriate, per surgical drain management and infection control standards in postoperative nursing care.

Choice D reason: Reinforcing dressings and assessing drainage addresses symptoms, not the cause of low drainage. Compressing the bulb restores suction, increasing drainage effectively. Dressings are secondary, per surgical drain management and postoperative wound care protocols in nursing practice.

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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

A client who had a radical neck dissection returns to the surgical unit with two surgical drains in the right side of the incision. One drain bulb is open and has minimal drainage. Which action should the nurse take to increase drainage into the drain?

Correct Answer is B

Explanation

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