The physician prescribes risperidone for a client with schizophrenia who displays delusions, hallucinations, apathy, and social isolation. Which symptoms should be monitored to evaluate improvement?

Both positive and negative symptoms.

Disorganized symptoms.

Negative symptoms.

Positive symptoms.

Answer and Explanation

The Correct Answer is A

Choice a reason:
Risperidone is an antipsychotic medication that can help manage both positive symptoms (such as delusions and hallucinations) and negative symptoms (such as apathy and social isolation) of schizophrenia. Monitoring both types of symptoms is essential to evaluate the overall effectiveness of the treatment. Positive symptoms are often more responsive to medication, while negative symptoms can be more challenging to treat and may require a comprehensive approach including psychosocial interventions.

Choice b reason:
Disorganized symptoms, which include disorganized speech and behavior, are another aspect of schizophrenia that can be impacted by risperidone. While these symptoms are not mentioned in the client's current presentation, they are still important to monitor as part of a comprehensive assessment of the client's condition.

Choice c reason:
Negative symptoms like apathy and social isolation can significantly impact a client's quality of life and functional abilities. Risperidone can help improve these symptoms, but they often require longer treatment duration and additional supportive therapies for significant improvement.

Choice d reason:
Positive symptoms such as delusions and hallucinations are critical targets for risperidone treatment. These symptoms can be distressing and disruptive, and their improvement is a key indicator of the medication's effectiveness. Monitoring the reduction or resolution of these symptoms is crucial for assessing the client's response to risperidone.

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Correct Answer is C

Explanation

Choice a reason:
Placing the client on 2L via nasal cannula is a common intervention for hypoxemia, but with the client's pulse oximetry at 88%, which is below the normal range of 95-100%, and the presence of tachypnea, a more immediate assessment of the client's respiratory status is warranted. Oxygen therapy should be guided by the results of arterial blood gas (ABG) analysis to tailor the treatment to the client's specific needs.

Choice b reason:
Obtaining a blood glucose level is not the most immediate concern in the context of altered mental status and respiratory distress. While it is important to rule out hypoglycemia as a cause of altered mental status, the primary concern indicated by the vital signs is the client's respiratory condition.

Choice c reason:
Calling the physician for an order for a stat arterial blood gas is the most appropriate action. The ABG will provide detailed information about the client's oxygenation, carbon dioxide levels, and acid-base balance. This is crucial for a client with a new onset change in mental status and tachypnea, as it can indicate respiratory failure or other serious complications of pneumonia.

Choice d reason:
Requesting an order for lorazepam is not appropriate given the client's current respiratory status. Lorazepam, a benzodiazepine, can depress the central nervous system and respiratory drive, potentially worsening the client's hypoxemia and respiratory effort.

A. Place the client on a 35% Venturi mask. B. Encourage the client to increase liquid intake throughout the day. C. Administer dextromethorphan 30 mg PO every six hours as needed. D. Encourage pursed-lip breathing when the client is out of bed.

Correct Answer is B

Explanation

Choice a reason:
Placing the client on a 35% Venturi mask would provide a controlled amount of oxygen which is beneficial for clients with chronic obstructive pulmonary disease (COPD) who may retain carbon dioxide. However, this intervention is not directly related to the management of a non-productive cough and difficulty expectorating secretions.

Choice b reason:
Encouraging the client to increase liquid intake throughout the day can help thin the bronchial secretions, making them easier to expectorate. Adequate hydration is essential in the management of chronic bronchitis to help clear mucus from the airways.

Choice c reason:
Administering dextromethorphan, a cough suppressant, may be used to control a non-productive cough. However, it would not assist with the expectoration of secretions and could potentially inhibit the cough reflex needed to clear the airways.

Choice d reason:
Encouraging pursed-lip breathing can help improve ventilation and oxygenation by promoting more effective exhalation. This technique can be beneficial for clients with COPD but does not directly address the issue of expectorating secretions.

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The physician prescribes risperidone for a client with schizophrenia who displays delusions, hallucinations, apathy, and social isolation. Which symptoms should be monitored to evaluate improvement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During an assessment of an anxious client diagnosed with right lower lobe pneumonia, the nurse notes a new onset change in mental status and tachypnea. The latest vital signs for the client are T: 98.4 F; HR: 108; RR: 28; BP: 144/90; Pulse ox: 88%. What is the priority nursing action?

Correct Answer is C

Explanation

A client with chronic bronchitis has a non-productive cough, rhonchi in bilateral lung fields, and difficulty expectorating the secretions. Which intervention should the nurse incorporate into the plan of care?

Correct Answer is B

Explanation

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