The nurse states in report that the client is experiencing positive symptoms of schizophrenia. What symptoms would the nurse receiving report expect to observe?
Flat affect and hygiene needs
Social isolation and anhedonia
Hallucinations and delusions
Withdrawal and avolition
The Correct Answer is C
A. Flat affect (lack of emotional expression) and hygiene needs are negative symptoms, not positive symptoms.
B. Social isolation and anhedonia (inability to experience pleasure) are also negative symptoms, not positive symptoms.
C. Positive symptoms involve the presence of abnormal experiences or behaviors that are not present in healthy individuals. Hallucinations (perceiving things that aren't there) and delusions (strongly held false beliefs) are examples of positive symptoms.
D. Withdrawal (lack of interest or participation in social activities) and avolition (lack of motivation) are negative symptoms, not positive symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "It sounds as though the antidepressants are working well. Just ask the client if the client is experiencing any side effects and let me know." This response does not adequately address the change in mood and the potential for hypomania. It assumes the change is solely due to the antidepressants.
B. "I'm concerned. Sometimes depressed people seem contented when they have decided to commit suicide. Let's schedule an appointment for tomorrow." While it's important to assess for suicidality, the description provided does not indicate immediate suicidal intent. The client's behavior is more indicative of hypomania.
C. "Since the client is eating, sleeping, and not behaving inappropriately, there's nothing to worry about. Just let me know if the client starts getting irritable or has trouble sleeping." This response downplays the significance of the mood change and does not address the potential for hypomania.
D. "The client sounds hypomanic. Let's schedule an appointment for this week for an evaluation. The client may need additional or different medication." This response correctly identifies the potential for hypomania and takes appropriate action by scheduling an evaluation. Adjusting the client's medication may be necessary to address the change in mood.
Correct Answer is D
Explanation
A) Incorrect. Reverse isolation is not indicated in this situation. The client's symptoms are likely due to a side effect of the medication, not an infectious process.
B) Incorrect. While it may be necessary to withhold the next dose of medication, the client's symptoms require more immediate attention.
C) Incorrect. The client's symptoms are indicative of a serious adverse reaction, and dietary changes would not address the issue.
D) Correct. The client's symptoms, including severe muscle stiffness, difficulty swallowing, drooling, diaphoresis, and elevated vital signs, are indicative of neuroleptic malignant syndrome (NMS), a potentially life-threatening side effect of antipsychotic medications like risperidone.
The nurse should notify the healthcare provider immediately for further guidance and intervention.
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