A 34-year-old male admitted with catatonic schizophrenia has been mute and motionless for sev-eral days while at home prior to admission. He still appears stuporous in the hospital. Which nursing intervention would be an initial priority?
1. Orienting the client to the unit
2. Assessing the client for physical problems
3. Establishing a nonthreatening relationship
4. Reinforcing reality with the client
ANS: 2
Clients who are mute and motionless and inattentive to environmental stimuli are at risk for a number of physical problems. Further, they are unable to communicate existing problems. The nurse must make thorough and astute assessments before creating plans to meet the client's needs. 1. A client who is stuporous may not be able to attend to information given about unit rules and protocols. 3. This is an important intervention but not the priority according to Maslow's hierarchy. 4. Because the client is mute, one can only suspect lack of reality orientation. While an appropriate intervention, it is not the priority according to Maslow's hierarchy.
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