Exhibits
A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse report to the provider? (Click on the “Exhibit” button for additional information about the client. There are three tabs that contain separate categories of data.)
Hallucinations
Temperature
Weight gain
Blood pressure
The Correct Answer is B
Choice A Reason: Hallucinations are a common symptom of schizophrenia and may not require immediate reporting to a provider unless they represent a change from the patient’s baseline or are causing distress.
Choice B Reason: The client’s temperature of 39.4° C (103° F) is significantly higher than the normal body temperature range of 36.5° C to 37.5° C (97.7° F to 99.5° F). This indicates a fever, which could suggest an infection or another acute health issue that requires immediate attention.
Choice C Reason: While weight gain is a concern for patients with schizophrenia, especially due to the potential side effects of medications like olanzapine, it is not typically an acute issue requiring immediate reporting unless it is rapid and significant, which could indicate other health problems.
Choice D Reason: The client’s blood pressure reading of 128/82 mm Hg falls within the normal range for adults, which is less than 120/80 mm Hg for normal blood pressure. Therefore, it does not need to be reported urgently.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: A blood glucose level of 256 mg/dL is significantly higher than the normal range and could indicate hyperglycemia, which is a serious side effect of risperidone. The provider should be notified immediately to manage this potential complication.
Choice B reason: A WBC count of 6,000/mm³ is within the normal range and does not typically warrant concern or the need to notify the provider.
Choice C reason: A platelet count of 250,000/mm³ is also within the normal range and is not indicative of an adverse reaction to risperidone.
Choice D reason: A sodium level of 140 mEq/L falls within the normal range and is not a cause for alarm in the context of risperidone therapy.
Correct Answer is A
Explanation
Choice A reason: Guided imagery is a relaxation technique that can help calm the mind and is beneficial for individuals with anxiety disorders. It involves envisioning a peaceful scene or series of experiences that can distract from anxious thoughts. This method can be particularly helpful before bedtime to ease the transition into sleep.
Choice B reason: Lying in bed and trying to force oneself to fall asleep can actually lead to increased frustration and anxiety, making it harder to fall asleep. It's recommended to leave the bed if unable to sleep and engage in a quiet activity until feeling sleepy.
Choice C reason: Eating a substantial meal before bed can lead to discomfort and disrupt sleep. It's better to have a light snack if needed and avoid heavy meals close to bedtime.
Choice D reason: Restricting sleep can exacerbate anxiety and is not recommended. It's important to maintain a regular sleep schedule and ensure adequate sleep to manage anxiety symptoms effectively.
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