A client with catatonic schizophrenia has been posturing, standing with his left arm upraised and his right foot off the floor
For the most part, he ignores attempts at nursing intervention but will occasionally walk, sit, or lie down for a few minutes. The client eats standing up if the nurse brings a tray to the room. The priority nursing order would be to:
1. Insist that client sit or lie down for 30 minutes hourly
2. Assess for lower extremity edema bid
3. Provide high-calorie drinks hourly
4. Take client to activities therapy once daily
ANS: 2
Clients who maintain one position for long periods of time should be assessed for dependent edema. In this case, the nurse would look for edema of the lower extremities and would be con-cerned about the pressure exerted by standing on one foot for long periods of time. 1. Insistence would probably be met with resistance by the client. 3. High-calorie drinks would be necessary if the client failed to eat at meals. 4. The client probably would not be able to cognitively process what is required to participate in activities.
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