A 34-year-old male admitted with catatonic schizophrenia has been mute and motionless for several days while at home prior to admission. He still appears stuporous in the hospi-tal. Which nursing intervention would be an initial priority?
a. Orienting the patient to the unit
b. Reinforcing reality with the patient
c. Establishing a nonthreatening relationship
d. Assessing the patient for physical problems
ANS: D
Patients 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 pa-tient's needs. A patient who is stuporous may not be able to attend to information given about unit rules and protocols. While establishing a therapeutic nurse-patient relationship is an important intervention, it does not have priority according to Maslow's hierarchy. Because the patient is mute, one can only suspect lack of reality orientation. While an appropriate in-tervention, it is not the priority according to Maslow's hierarchy.
You might also like to view...
A nurse is preparing a client for discharge after surgery. The client needs to change a large dressing and manage a drain at home. What instruction by the nurse is most important?
a. "Be sure you keep all your postoperative appointments." b. "Call your surgeon if you have any questions at home." c. "Eat a diet high in protein, iron, zinc, and vitamin C." d. "Wash your hands before touching the drain or dressing."
Which of the following Medicaid clients would most likely receive case management?
a. An elderly person b. A person receiving rehabilitation following an injury c. A person who has a high-cost chronic disease d. A person with acute illness
A nursing instructor has been discussing abuse with a group of students. Which statement by a student indicates a need for further education?
A) "Factors that contribute to abuse in families include unemployment, substance abuse, and chronic illness." B) "Many abused children grow up and abuse their own children." C) "Changing abusive patterns is easy once they are detected." D) "Abuse can happen in any socioeconomic status."
The urinal should be stored
A. on the overbed table so the patient can reach it. B. on the back of the toilet in the bathroom. C. by hanging it on the side rail. D. in the bedside stand.