The nurse is caring for a client with schizotypal personality disorder who was experiencing transient psychotic episodes that led to admission. The client was unkempt and appeared not to have bathed for quite some time. When planning the care of this client, which will be the focus of the nursing interventions? Select all that apply.

Encourage the client to seek a hobby.

Establishing close relationships with others.

Improve functioning in the community.

Development of social skills.

Development of self-care skills.

Answer and Explanation

Correct Answer : C,D,E

Choice A reason: While hobbies can be therapeutic, they are not the primary focus of nursing interventions for a client with schizotypal personality disorder and hygiene issues.

Choice B reason: Establishing close relationships is beneficial but may not be the immediate focus for a client who is struggling with basic self-care.

Choice C reason: Improving functioning in the community is a key goal for clients with schizotypal personality disorder to help them integrate better into society.

Choice D reason: Developing social skills is essential for clients with schizotypal personality disorder to interact more effectively with others.

Choice E reason: Development of self-care skills is crucial, especially given the client's unkempt appearance and lack of bathing, indicating a need for better personal hygiene practices.

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 D

Explanation

Choice A reason: Gastric lavage is not indicated in this scenario as the client's lithium level is not extremely elevated. Gastric lavage is typically reserved for cases of acute lithium toxicity when levels are significantly higher than the therapeutic range.

Choice B reason: There is no need to hold the medication as the lithium level is within the normal therapeutic range, which is generally between 0.6 to 1.2 mEq/L. Early manifestations of toxicity typically occur at levels above 1.5 mEq/L.

Choice C reason: Checking the client's medication record is a standard procedure but does not take precedence over administering the medication. The lithium level indicates that the client has been compliant with the medication regimen.

Choice D reason: The nurse should administer the morning dose of lithium because the current level is within the therapeutic range, indicating that it is safe to continue the prescribed treatment.

A. Check the client's pupil reactivity. B. Perform a developmental screening test. C. Prepare the client for a CT scan. D. Obtain a urine specimen. E. Monitor the client’s vital signs frequently.

Correct Answer is ["A","C","D","E"]

Explanation

Choice A Reason:

Checking the client's pupil reactivity is important because alcohol intoxication can affect the nervous system, which may be reflected in changes in pupil size and reactivity to light. Normal pupil size ranges from about 2 to 4 mm in diameter in bright light to 4 to 8 mm in the dark. Pupils that do not respond to light could indicate a neurological deficit that requires immediate attention.

Choice B Reason:

Performing a developmental screening test is not typically indicated for acute alcohol intoxication management. Developmental screenings are generally used to assess children for appropriate growth and developmental milestones, not for adults in an emergency setting due to intoxication.

Choice C Reason:

Preparing the client for a CT scan may be necessary if there is a suspicion of head trauma or intracranial bleeding, which can occur with falls or injuries associated with intoxication. A CT scan can help identify any urgent issues that need to be addressed.

Choice D Reason:

Obtaining a urine specimen can be useful for several reasons. It can be tested for the presence of alcohol, other substances, or toxins. Additionally, it can provide information about the client's overall health and kidney function.

Choice E Reason:

Monitoring the client’s vital signs frequently is crucial. Alcohol intoxication can lead to vital sign abnormalities such as hypotension, tachycardia, or respiratory depression. Normal ranges for vital signs vary but generally include a blood pressure of 90/60 mmHg to 120/80 mmHg, a heart rate of 60 to 100 beats per minute, and a respiratory rate of 12 to 20 breaths per minute.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an acute care mental health facility is preparing to administer morning medication to a client who has been taking lithium for 2 weeks and has a current lithium level of 1.0 mEq/L. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse in the emergency department is creating a plan of care for a client experiencing alcohol intoxication. Which of the following interventions should the nurse plan to include? Select all that apply.

Correct Answer is ["A","C","D","E"]

Explanation

A nurse is caring for a client who is extremely suspicious of the nursing staff and other clients. Which of the following nursing approaches is appropriate when establishing a therapeutic relationship with this client?

Which is a psychosocial explanation for the development of personality disorders?

The nurse is educating a client about their diagnosis of somatization disorder prior to the termination phase of the nurse-client relationship. Which statement by the client indicates a need for additional teaching?

A nurse is working with clients diagnosed with personality disorders. Which techniques would be most important for the nurse to use to effectively deal with the frustration in providing care to this group of clients? Select all that apply.

A nurse is caring for a client who has an extremely elevated lithium level. Which of the following actions should the nurse take?

A client has a history of excessive fear of water. Which term should the nurse use to describe this specific phobia, and under what subtype is this phobia identified?

The nurse is planning the type of approach that will be most effective in developing a therapeutic relationship with the client. With which types of personality disorders should the nurse use a matter-of-fact approach? (Select all that apply)