The nurse is interviewing a newly admitted client. Which of the following nursing statements is an example of offering a "general lead"?

"Can you order the specific events that led to your admission?"

"Do you know why you are here?"

"Are you feeling depressed or anxious?"

"Yes, I see. Go on."

Answer and Explanation

The Correct Answer is D

a. "Can you order the specific events that led to your admission?" This statement directs the client to provide specific information and is more focused than a general lead. It does not encourage a broad response.
b. "Do you know why you are here?" This question is somewhat open-ended but still directs the client's response toward understanding their admission.
c. "Are you feeling depressed or anxious?" This question is specific and closed-ended, prompting a choice between two options rather than encouraging the client to freely elaborate.
d. "Yes, I see. Go on." This is correct because it encourages the client to continue speaking without directing the topic, which is the essence of a general lead.

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Correct Answer is B

Explanation

a. Psychotic disorder: Schizophrenia is a well-defined psychotic disorder characterized by delusions, hallucinations, and disorganized thinking, but it doesn't specifically address the mood component present in this case.
b. Schizoaffective disorder: Schizoaffective disorder is characterized by symptoms of both schizophrenia (such as delusions and hallucinations) and mood disorders (such as depression or mania). The presence of delusional thinking and visual hallucinations, combined with periods of depression and suicidal ideations, fits the profile of schizoaffective disorder.
c. Paranoid disorder: Paranoid disorder is characterized by a pervasive pattern of suspicion and distrust, but it doesn't necessarily involve hallucinations or disorganized thinking like schizophrenia.
d. Schizophreniform disorder: Schizophreniform disorder is similar to schizophrenia but with a shorter duration of symptoms (less than 6 months). The prompt doesn't specify the duration, making schizophrenia a more likely diagnosis.

A. Administer the 6mg Benztropine orally with a full glass of water on an empty stomach. B. Ask the healthcare provider to increase the dose of Haloperidol to assist with the side effect. C. Hold the dose of Haloperidol and notify the healthcare provider. D. Explain to the client that the side effects should diminish in one to two weeks.

Correct Answer is C

Explanation

a. Administer the 6mg Benztropine orally with a full glass of water on an empty stomach: Benztropine is an anticholinergic medication used to manage the extrapyramidal side effects (EPS) of antipsychotics. However, it's important to consult the healthcare provider before administering any additional medications.
b. Ask the healthcare provider to increase the dose of Haloperidol to assist with the side effect: Increasing the dose of Haloperidol might worsen the tardive dyskinesia symptoms.
c. Hold the dose of Haloperidol and notify the healthcare provider. (Correct) Haloperidol is an antipsychotic medication with a known side effect of tardive dyskinesia, which manifests as involuntary facial and body movements. Stopping the medication and informing the provider is crucial to determine the best course of action, which might involve dose adjustment or switching medications

d. Explain to the client that the side effects should diminish in one to two weeks: Tardive dyskinesia can be a persistent side effect, and reassurance without addressing the medication is not helpful.

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The nurse is interviewing a newly admitted client. Which of the following nursing statements is an example of offering a "general lead"?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a schizophrenic client who is exhibiting delusional thinking, visual hallucinations, suicidal ideations, and periods of depression. The nurse would recognize that the client is displaying which category of schizophrenia?

Correct Answer is B

Explanation

The nurse is assessing a client diagnosed with schizophrenia, who has been prescribed Haloperidol for the past year. On assessment, the nurse notices that the client is demonstrating bizarre facial and tongue movements. What is the priority nursing intervention?

Correct Answer is C

Explanation

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