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 B
Explanation
Choice A reason: An altered level of consciousness is not typically associated with Alzheimer's disease. Patients with Alzheimer's may experience confusion or disorientation, but changes in consciousness, such as stupor or coma, are not characteristic symptoms of the disease.
Choice B reason: Failure to recognize familiar objects, known as agnosia, is a common finding in Alzheimer's disease. As the disease progresses, the ability to recognize objects, faces, and even sounds can be impaired, which is a direct result of the deterioration of brain areas involved in processing sensory information.
Choice C reason: Excessive motor activity is not a common finding in Alzheimer's disease. While patients may experience restlessness, the disease often leads to a decrease in overall activity levels due to cognitive decline and the eventual difficulty with coordination and motor functions.
Choice D reason: Rapid mood swings can occur in Alzheimer's disease, but they are not as prominent as other cognitive symptoms. Mood changes in Alzheimer's are usually a result of the frustration and confusion experienced by the patient rather than a direct symptom of the disease itself.
Correct Answer is B
Explanation
Choice A reason: Providing detailed explanations to a client with moderate anxiety might overwhelm them and exacerbate their anxiety. While information is important, too much detail can be counterproductive in this context.
Choice B reason: Using short, simple sentences can help ensure that the client with moderate anxiety comprehends the information without becoming overwhelmed. This approach is conducive to learning and retention, especially when the client is anxious.
Choice C reason: Avoiding asking the client questions may seem like a way to reduce stress, but it can actually hinder engagement and understanding. Questions can help clarify the client's comprehension and provide them with a sense of involvement in their care.
Choice D reason: Showing a 30-minute teaching video might be informative, but it could be too lengthy for a client with moderate anxiety. The client may benefit more from interactive and personalized teaching methods that allow for breaks and questions as needed.
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