Difficulty: Medium
Average Score: 78%
Simulated
Passage / Scenario
Nurses' Notes2200:
According to the police officer's report, the client was found sleeping near railroad tracks. Refused to give name, and no identification found. Client states they were, "Just doing what they were told to do. Didn't know it would take so long for the train to come." Client appears disheveled with poor hygiene. Client does not follow simple commands, refuses to answer questions, and will not make eye contact.
2230:
Client refusing to follow prescribed treatment plan. States they believe someone is trying to poison them. Noted to occasionally be mumbling as if talking to unseen others.
Provider Prescriptions
2200:
Clozapine 200 mg PO twice per day
Risperidone 4 mg PO twice per day
A nurse in a mental health facility is admitting a client who was brought in by the police department. Exhibits:Complete the diagram by selecting from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
Correct answer
A, A,C, B,D
Rationale
Action to Take: A, A; Potential Condition: C; Parameter to Monitor: B, D.
Rationale: The client is likely experiencing schizophrenia based on brought in by the police, so actions to take include providing a safe environment (placing client in a room near the nurses' station) and administering antipsychotic medications to address the condition. Potential condition of seizures (C) should be monitored closely. Parameters to monitor include behavior changes (B) and medication efficacy (D) to assess progress and ensure safety. Other choices are incorrect as they do not align with the client's likely condition or best practices in mental health care.
Rationale: The client is likely experiencing schizophrenia based on brought in by the police, so actions to take include providing a safe environment (placing client in a room near the nurses' station) and administering antipsychotic medications to address the condition. Potential condition of seizures (C) should be monitored closely. Parameters to monitor include behavior changes (B) and medication efficacy (D) to assess progress and ensure safety. Other choices are incorrect as they do not align with the client's likely condition or best practices in mental health care.