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When assessing a client for possible disordered water balance, the nurse checks the client?s urine specific gravity. Which result would lead the nurse to suspect that the client is experiencing severe disordered water balance?
- A. 1.02
- B. 1.011
- C. 1.005
- D. 1.002
Correct Answer: D
Rationale: A urine specific gravity of 1.002 (D) is extremely low, indicating overly dilute urine, consistent with severe disordered water balance (e.g., psychogenic polydipsia). Normal range is 1.010?1.030, so 1.020 (A) and 1.011 (B) are closer to normal, and 1.005 (C) is less severe.
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After assessing a client with schizophrenia, the nurse suspects that the client is experiencing an anticholinergic crisis. Which of the following would the nurse most likely have assessed? Select all that apply.
- A. Dilated reactive pupils
- B. Blurred vision
- C. Ataxia
- D. Coherent speech
- E. Facial pallor
- F. Disorientation
Correct Answer: B,C,F
Rationale: Anticholinergic crisis symptoms include blurred vision (B), ataxia (C), and disorientation (F) due to excessive anticholinergic effects (e.g., from medications). Dilated pupils (A) may occur but are less specific, coherent speech (D) is unlikely, and facial pallor (E) is not typical.
The nurse is caring for a client who was diagnosed with schizoaffective disorder. Based on the nurse?s understanding of this disorder, the nurse develops a plan of care to address which issue as the top priority?
- A. Suicide
- B. Aggression
- C. Substance abuse
- D. Eating disorder
Correct Answer: A
Rationale: Suicide (A) is the top priority in schizoaffective disorder due to the combined risk of mood disturbances (e.g., depression) and psychosis, both of which elevate suicide risk. Aggression (B), substance abuse (C), and eating disorders (D) are concerns but less immediate unless actively present.
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.
While assessing a client with schizophrenia, the client states, Everywhere I turn, the government is watching me because I know too much. They are afraid that I might go public with the information about all those conspiracies. The nurse interprets this statement as indicating which type of delusion?
- A. Grandiose
- B. Nihilistic
- C. Persecutory
- D. Somatic
Correct Answer: C
Rationale: The client?s belief that the government is watching them due to their knowledge reflects a persecutory delusion (C), characterized by fears of harm or surveillance. Grandiose delusions (A) involve inflated self-importance, nihilistic delusions (B) involve beliefs in nonexistence, and somatic delusions (D) focus on bodily concerns.
A client with schizoaffective disorder is having difficulty adhering to the medication regimen that requires the use of several agents. The client also is experiencing several side effects contributing to this nonadherence. The physician plans to change the client?s medication. Which agent would the nurse anticipate that the physician would prescribe?
- A. Lithium
- B. Aripiprazole
- C. Clozapine
- D. Olanzapine
Correct Answer: B
Rationale: Aripiprazole (B) is a second-generation antipsychotic with a favorable side effect profile and efficacy for schizoaffective disorder, improving adherence. Lithium (A) is for mood stabilization, clozapine (C) is for treatment-resistant cases, and olanzapine (D) has more side effects.