While assessing a client with the diagnosis of schizophrenia who wears dentures, the nurse observes that the client’s tongue is “worming”. The client also demonstrates an inability to articulate words clearly. Which additional assessment is most important for the nurse to obtain?

Usual level of activity and average sleep pattern.

Blood pressure when sitting and standing.

Dentures to determine if they are poorly fitted.

Body weight over the past three months.

Answer and Explanation

The Correct Answer is C

A.   Assessing the usual level of activity and average sleep pattern is relevant but does not directly address the observed symptoms related to speech and tongue movements.
B.   Blood pressure assessment is important for overall health monitoring but is not the most immediate concern related to the observed speech and tongue abnormalities.
C. Assessing the fit of dentures is crucial in this context, as poorly fitted dentures could contribute to speech difficulties and tongue abnormalities.
D.   Body weight assessment is important for overall health but is not the most immediate concern in this situation. Assessing denture fit addresses the observed speech and tongue abnormalities more directly.

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Correct Answer is A

Explanation

A. Feeling angry, embarrassed, and helpless may indicate subconscious blame or judgment toward the client for staying in an abusive relationship. It's important for the nurse to recognize and address these feelings to provide non-judgmental and supportive care.
B. Difficulty accepting the explanation about how the injuries occurred could contribute to these feelings, but it is not the primary cause in this context.
C. Limited experience in caring for clients affected by family violence may contribute to discomfort, but it does not explain the specific emotions described.
D. While a personal history of abuse could impact the nurse's feelings, the question is asking for the immediate cause of the emotions during the current interaction with the client.

A. Advise the mother to call the police if violent behavior occurs again. B. Refer the mother for psychiatric evaluation for anxiety and depression. C. Reinforce the need for the adolescent to attend group therapy sessions. D. Tell the mother to describe her feelings of helplessness to her son.

Correct Answer is A

Explanation

A. Advising the mother to call the police if violent behavior occurs again addresses the safety of the client and others and is a necessary step to ensure appropriate intervention.
B. Referring the mother for psychiatric evaluation is important but may not directly address the immediate safety concern related to the recent violent behavior.
C. Reinforcing the need for the adolescent to attend group therapy sessions is relevant, but the immediate focus should be on addressing the safety issue.
D. Telling the mother to describe her feelings may be helpful for therapeutic communication but may not be the most urgent intervention in response to the reported violent behavior.

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While assessing a client with the diagnosis of schizophrenia who wears dentures, the nurse observes that the client’s tongue is “worming”. The client also demonstrates an inability to articulate words clearly. Which additional assessment is most important for the nurse to obtain?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who has been the victim of intimate partner violence. During the interview, the nurse feels angry, embarrassed, and helpless. Which explanation best describes the cause of the nurse’s emotions?

Correct Answer is A

Explanation

Correct Answer is A

Explanation

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