Which nursing documentation entry accurately describes a client's use of confabulation?

The nurse states in report that the client is experiencing positive symptoms of schizophrenia. What symptoms would the nurse receiving report expect to observe?

While conducting an admission interview with a client, the nurse suspects the client may be in alcohol withdrawal. Which screening tool can help the nurse identify the severity of withdrawal symptoms?

Which nursing documentation entry accurately describes a client's use of confabulation?

The mother of a 20yearold woman recently diagnosed with paranoid schizophrenia asks the nurse what causes schizophrenia. The nurse recognizes which of the following are implicated in the etiology of schizophrenia?

A client receiving risperidone reports severe muscle stiffness at 1030. By 1200, the client has difficulty swallowing food and is drooling. The client is diaphoretic. By 1600, vital signs are as follows Temperature 102.8 F pulse 110 beats/minute, respirations 26 breaths/minute, and blood pressure 150/90 mmHg.

What is the nurse's best analysis and action?

A client has been diagnosed with major depression and placed on amitriptyline. Which is a side effect of amitriptyline?

A client diagnosed with major depressive disorder with psychotic features hears voices commanding self harm. The client refuses to commit to developing a plan for safety. What should be the nurse's priority intervention at this time?

Which of the following is the most therapeutic response by the nurse when a client states, "I no longer need my medication since I do not hear voices"?

The nurse is caring for a client who has become increasingly agitated. He is pacing in the hallway and shouting at other clients. What is the priority action of the nurse?

A nurse in the emergency department is implementing a plan of care for an older adult client who is experiencing delirium tremens. Which of the following actions should the nurse take first?