The nurse notices a client wandering in the hospital hall giggling, with bizarre behavior that is annoying and frightening other clients. A priority in caring for her is to:

Encourage social interaction.

Discuss the bizarre behavior.

Give the client information about her illness.

Provide a safe environment.

Answer and Explanation

The Correct Answer is D

Choice A Reason:

Encouraging social interaction might not be appropriate in this situation. The client’s bizarre behavior is already causing distress to others, and encouraging more interaction could exacerbate the problem. The priority should be to address the immediate safety and well-being of both the client and others. Once the client is in a safe environment, social interaction can be encouraged in a controlled and therapeutic manner.

Choice B Reason:

Discussing the bizarre behavior with the client might not be effective in the moment, especially if the client is not in a state to understand or engage in such a discussion. The primary focus should be on ensuring safety and stability before addressing specific behaviors. Once the client is calm and in a safe environment, discussions about behavior can be more productive.

Choice C Reason:

Providing information about the client’s illness is important for long-term management and understanding, but it is not the immediate priority in this situation. The client’s current state requires immediate intervention to ensure safety. Education about the illness can be provided once the client is stabilized and in a better position to comprehend the information.

Choice D Reason:

Providing a safe environment is the most immediate and crucial priority. The client’s behavior is not only distressing to others but could also pose a risk to herself and others. Ensuring the client is in a safe, controlled environment helps to prevent harm and allows for further assessment and appropriate interventions. Safety is always the first priority in managing acute behavioral disturbances.

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Correct Answer is C

Explanation

Choice A Reason:

Manifestation of dyslexia.

Dyslexia is a learning disorder characterized by difficulties with accurate and/or fluent word recognition and by poor spelling and decoding abilities. It is not typically associated with the creation of new words or phrases, which is what the term ‘mazurka’ represents in this context. Therefore, the client’s use of ‘mazurka’ is not a manifestation of dyslexia.

Choice B Reason:

Example of loose associations.

Loose associations refer to a thought disorder where ideas are presented with little or no logical connection between them. While this is a common symptom in schizophrenia, it does not specifically involve the creation of new words. The term ‘mazurka’ in this context does not illustrate a lack of logical connection between ideas but rather the invention of a new term.

Choice C Reason:

Neologism.

Neologism refers to the creation of new words or phrases that are often only understood by the person who created them. This is a common symptom in schizophrenia, where individuals may invent words that have meaning only to them. The client’s use of ‘mazurka’ fits this definition, as it is a newly created word that likely holds specific meaning for the client.

Choice D Reason:

Flight of ideas.

Flight of ideas is a symptom characterized by rapid and continuous speech with abrupt changes from topic to topic, usually based on understandable associations, distracting stimuli, or plays on words. This symptom is more commonly associated with manic episodes rather than schizophrenia. The use of ‘mazurka’ does not indicate rapid topic changes but rather the creation of a new word.

A. This will help with medication compliance. B. It will help him remember to take his medication. C. This has a faster onset of action. D. This new medication is stronger and will clear his symptoms faster.

Correct Answer is A

Explanation

Choice A Reason:

This will help with medication compliance.

This is the correct response. Long-acting injectable (LAI) antipsychotics like risperidone IM are often used to improve medication compliance in patients who have difficulty remembering to take their oral medications regularly. By administering the medication every two weeks, the treatment team can ensure that the client receives a consistent dose, reducing the risk of relapse due to missed doses. This approach is particularly beneficial for clients with schizophrenia, as consistent medication adherence is crucial for managing symptoms and preventing hospitalizations.

Choice B Reason:

It will help him remember to take his medication.

While this statement is related to medication compliance, it is not entirely accurate. The purpose of switching to an injectable form is to eliminate the need for the client to remember to take daily doses. Instead, the healthcare provider administers the medication at regular intervals, ensuring adherence without relying on the client’s memory.

Choice C Reason:

This has a faster onset of action.

This statement is incorrect. The onset of action for long-acting injectable risperidone is not necessarily faster than the oral form. In fact, LAIs are designed to release the medication slowly over time to maintain stable blood levels. The primary advantage of LAIs is improved adherence, not a faster onset of action.

Choice D Reason:

This new medication is stronger and will clear his symptoms faster.

This statement is also incorrect. The strength of the medication and the speed at which it clears symptoms are not the primary reasons for switching to an injectable form. The goal is to ensure consistent medication levels and improve adherence, not to increase the potency or speed of symptom relief.

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The nurse notices a client wandering in the hospital hall giggling, with bizarre behavior that is annoying and frightening other clients. A priority in caring for her is to:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a diagnosis of schizophrenia says to the student nurse, “The mazurkas are coming. The mazurkas are coming.” The client’s use of the word ‘mazurka’ is most likely a/an:

Correct Answer is C

Explanation

A client is having trouble remembering to take his antipsychotic medication, risperidone 3 mg PO, BID. The treatment team at the clinic he attends is considering starting him on risperidone 10 mg IM every 2 weeks. The rationale for this is:

Correct Answer is A

Explanation

A nurse is caring for a client who has schizophrenia and is experiencing command auditory hallucinations. Which of the following actions should the nurse take?

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