The nurse is continuing to care for the client. 

Exhibits

The nurse is reviewing the assessment findings.

For each assessment finding, click to specify if the finding is consistent with preeclampsia or HELLP syndrome. Each finding may support more than one disease process.

Rationale:

A. Client's chief complaint: Hearing voices is an auditory hallucination, which is a hallmark positive symptom of schizophrenia. Hallucinations reflect a distortion of reality and are typically responsive to antipsychotic treatment.

B. Client's job performance history: Poor job performance reflects functional decline, which is a negative symptom (e.g., avolition or anhedonia), not a positive one. It indicates loss of normal function rather than distortion.

C. Client's relationships with family and friends: Social withdrawal is another negative symptom, reflecting a lack of interest or emotional engagement. Positive symptoms are additions to normal experience, not losses like this.

D. Client's copying nurses' words: Repeating others’ words is known as echolalia, a disorganized thought manifestation commonly seen in schizophrenia. It indicates impaired cognitive processing and communication.

E. Client's statement about their mother: The delusional belief that their mother is trying to kill them represents a paranoid delusion, a classic positive symptom. Such fixed false beliefs are unrelated to reality and resistant to logic.

F. Client's speech pattern: Unclear, jumbled, and disorganized speech reflects disorganized thinking, another positive symptom of schizophrenia. This makes coherent communication and goal-directed behavior difficult.

Rationale:

A. Instruct the client to have his testosterone checked in 1 week: Testosterone levels are typically monitored after several weeks of therapy, not within just one week. Early testing may not accurately reflect the medication's effectiveness or stability in the bloodstream.

B. Wear clean gloves to apply the gel: Gloves must be worn, but they should be disposable and protective not simply clean gloves. This prevents accidental transdermal absorption of testosterone by the nurse, which can have hormonal effects, especially in females.

C. Apply the gel to the client's genital region: Testosterone gel should not be applied to the genital area due to the risk of irritation and unpredictable absorption. Recommended sites include the shoulders, upper arms, or abdomen where the skin is intact and dry.

D. Advise the client to wait 1 hr before showering or swimming: The client should be instructed to wait at least 1 hour to allow for full absorption of the gel. Showering or swimming too soon can reduce the effectiveness of the medication.