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","B"]

Explanation

A. Shielding the client from direct sunlight is important because some antipsychotic medications, including haloperidol, can increase sensitivity to sunlight, leading to sunburn.
B. Gradually withdrawing the medication over several days is a prudent approach to avoid withdrawal symptoms and potential worsening of symptoms.
C. Enforcing a fluid restriction is not typically necessary during dosage adjustment for antipsychotic medications like haloperidol.
D. Increasing the dosage if the white blood cell count drops is not a standard practice during the dosage adjustment of antipsychotic medications. Monitoring for adverse effects and adjusting the dosage accordingly is important, but the decision should be based on a comprehensive assessment rather than a single laboratory value.

A. Sleep deprivation related to state of hyperactivity. B. Ineffective coping related to biochemical changes. C. Risk for self-directed violence related to impulsive behavior. D. Imbalanced nutrition related to caloric expenditure.

Correct Answer is C

Explanation

A. While sleep deprivation is a concern, the client's impulsive behavior poses a greater immediate risk, making "Risk for self-directed violence related to impulsive behavior" the priority.
B. Ineffective coping may be a contributing factor, but the risk of self-directed violence takes precedence as the primary concern.
C. The client's impulsive behavior increases the risk of self-directed violence, making it the most urgent nursing priority.
D. Imbalanced nutrition is a concern, but the immediate risk of self-directed violence requires more immediate attention.

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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

A client diagnosed with schizophrenia has been receiving haloperidol for the past year, and the treatment plan includes moving the client to a lower maintenance dosage. Which intervention should the nurse include in this client’s plan of care? (Select all that apply)

Correct Answer is ["A","B"]

Explanation

Correct Answer is C

Explanation

The nurse develops a plan of care for a female client who scratches her wrists in attempts to deal with anxiety. Which client outcome is most important to include in the plan of care?

A client with post-traumatic stress disorder (PTSD) is experiencing a dissociative disorder episode. The situation quickly escalates, and the client becomes physically aggressive. Which intervention should the nurse implement first?

Which individual should the nurse consider at the highest risk for suicide?

The nurse is caring for a client who is a refugee from another country and who is experiencing daily episodes of anxiety. The client communicates minimally with the nurse, looking away and appearing distressed. Which intervention is most important for the nurse to do first?

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A client is admitted to an inpatient psychiatric unit, and the antipsychotic medication clozapine is prescribed. Which intervention should the nurse include in this client’s plan of care?

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