Nokea
A client has been diagnosed with schizophrenia. Assessment reveals that the client lives alone. His clothing is disheveled, his hair is uncombed and matted, and his body has a strange odor. During an interview, the client?s family voices a desire for the client to live with them when he is discharged. Based on the assessment findings, which nursing diagnosis would be the priority?
- A. Ineffective Role Performance related to symptoms of schizophrenia.
- B. Social Isolation related to auditory hallucinations.
- C. Dysfunctional Family Processes related to psychosis.
- D. Bathing Self-Care Deficit related to symptoms of schizophrenia.
Correct Answer: D
Rationale: Bathing Self-Care Deficit (D) is the priority nursing diagnosis, as the client?s disheveled appearance, matted hair, and body odor indicate an immediate inability to maintain personal hygiene, which affects health and social integration. Ineffective Role Performance (A) and Social Isolation (B) are relevant but secondary, and Dysfunctional Family Processes (C) is not supported by the family?s supportive stance.
You may also like to solve these questions
The nurse is preparing to interview a client who has a delusional disorder. Which of the following would the nurse expect?
- A. Cognitive impairment
- B. Normal behavior
- C. Labile affect
- D. Evidence of motor symptoms
Correct Answer: B
Rationale: Clients with delusional disorder typically exhibit normal behavior (B) outside their specific delusions, with intact cognition and affect. Cognitive impairment (A), labile affect (C), and motor symptoms (D) are more characteristic of other psychotic disorders like schizophrenia.
A client with schizophrenia tells the nurse, I?m being watched constantly by the FBI because of my job. Which response by the nurse would be most appropriate?
- A. Tell me more about how you are being watched.
- B. It must be frightening to feel like you?re always been watched.
- C. You?re not being watched; it?s all in your mind.
- D. You are experiencing a delusion because of your illness.
Correct Answer: B
Rationale: Empathizing with the client?s fear (B) validates their emotions without reinforcing the delusion, fostering trust. Asking for more details (A) may entrench the delusion, while dismissing (C) or labeling it (D) could alienate the client.
While caring for a hospitalized client with schizophrenia, the nurse observes that the client is listening to the radio. The client tells the nurse that the radio commentator is speaking directly to him. The nurse interprets this finding as which of the following?
- A. Autistic thinking
- B. Concrete thinking
- C. Referential thinking
- D. Illusional thinking
Correct Answer: C
Rationale: Referential thinking (C) describes the client?s belief that neutral events, like a radio broadcast, are personally directed at them, a common delusion in schizophrenia. Autistic thinking (A) involves private, illogical thoughts, concrete thinking (B) is overly literal interpretation, and illusional thinking (D) is not a standard term, making them incorrect.
A group of nursing students is reviewing information about other psychotic disorders. The students demonstrate understanding of this information when they identify which disorder as involving an inducer?
- A. Brief psychotic disorder
- B. Schizophreniform disorder
- C. Shared psychotic disorder
- D. Psychotic disorder attributable to a substance
Correct Answer: C
Rationale: Shared psychotic disorder (C), or folie à deux, involves an inducer who transmits delusional beliefs to another person. Brief psychotic disorder (A) is time-limited, schizophreniform disorder (B) mimics schizophrenia, and substance-induced psychosis (D) is caused by substances, not an inducer.
The nurse is caring for a client in an inpatient mental health setting. The nurse notices that when the client is conversing with other clients, he repeats what they are saying word for word. The nurse interprets this finding and documents it as which of the following?
- A. Echopraxia
- B. Neologisms
- C. Tangentiality
- D. Echolalia
Correct Answer: D
Rationale: Echolalia (D) is the correct term for the client?s behavior of repeating others? words verbatim, a common symptom in schizophrenia or other psychotic disorders, reflecting impaired communication processing. Echopraxia (A) involves mimicking movements, not speech. Neologisms (B) are made-up words, and tangentiality (C) refers to responses that veer off-topic, neither of which apply here.