The nurse at a mental health clinic is conducting an initial assessment on a patient who has been referred by the student health center at the university the patient attends. The patient had been brought to the health center by a member of the faculty

Question

when the patient began hallucinating during class. Which factor revealed during the assessment will the nurse consider a priority for care?
1. The patient has poor hygiene.
2. The patient is 20 years old.
3. The patient is single and lives off campus with a roommate who "is never around."
4. The patient's grades have plummeted this semester.

Answer 1

Answer: 3
Explanation: The single adult patient with initial onset schizophrenia with active hallucinations and/or delusions is at risk for injury due to the active state of illness and the patient's lack of knowledge about the illness. The fact that the patient lives essentially alone in an off campus apartment suggests he may have little in the way of support or observation. The patient's age, poor hygiene, and plummeting grades support the diagnosis of mental illness but are not the priority consideration in planning care.