[Answered]: Adam is a 36-year-old man of European descent

Adam is a 36-year-old man of European descent. He is accompanied to the ED by his caseworker and the police. Adam would not let the caseworker into his apartment and therefore the police had to forcibly enter the apartment. Adam has not been taking his psychiatric medications for 4 months. Reason for visit: escorted by caseworker and police, concern re: danger to himself, not adhering to community treatment Chart Data: Medical History: schizophrenia disorder past suicide attempts Social History: lives alone Initial Assessment: poor eye contact disheveled, dirty uncombed hair, and stained clothes looks at the corner of the room and then look down mumbling denies current suicidal ideation 10 pound weight loss in the past 2 weeks sleeping 12 hours daily not leaving the apartment client reports “he does not want to leave the apartment because someone is waiting to kill him” 1) RECOGNIZE CUES: The nurse observes Adam looking to the corner of the room and mumbling to himself. What does this behaviour suggest? Question 8 options: Auditory hallucinations, negative symptoms Tactile hallucinations, positive symptoms Visual hallucinations, positive symptoms Delusions, positive symptoms Gustatory hallucinations, negative symptoms Olfactory hallucinations, negative symptoms Question 9 (1 point) 2) Adam explains that someone has followed him to the emergency department (ED) and is waiting outside the of the ED door. ANALYZE CUES: What thought process describes the client’s inability to leave his apartment because he thinks someone is waiting to kill him? Question 9 options: Phobia. Delusions. Confabulation. Hallucinations. Question 10 (1 point) 3) Adam is requesting to leave the ED despite his fears. ANALYZE CUES: According to the Mental Health Act, what assessment findings indicate that Adam meets the criteria for involuntary admission for treatment? Question 10 options: Past history of suicide attempts Auditory hallucinations Weight loss of 10 lbs in 2 weeks Threatening harm to others Delusions Question 11 (1 point) 4) The physician completes an admission certificate which can hold Adam in-hospital for 24 hours (Form 1). After admission he must be reassessed (usually by 2 physicians/psychiatrist) so they he can be involuntarily admitted for up to 1 month. PRIORITIZE HYPOTHESES: What would your priority nursing diagnosis be for Adam? Question 11 options: Disturbed sleep pattern related to negative symptoms of schizophrenia as evidenced by client reports sleeping 12 hours per day. Chronic low self-esteem related to unmanaged schizophrenia as evidenced by disheveled and dirty appearance Social isolation related to delusions as evidenced by fear of leaving the apartment and withdrawal. Acute confusion related to unmanaged schizophrenia as evidenced by hallucinations, delusions and lack of self-care. Question 12 (1 point) 5) GENERATE SOLUTIONS: What interventions should the nurse include in the care plan to address Adam’s hallucinations while he is an in-patient? Select 4. Select 4 correct answer(s) Question 12 options: Education that hallucinations and delusions are a normal part of the disorder. Activities for distraction. Education on potential triggers for hallucinations. Acknowledgement and validation that the hallucinations are frightening. Education on how to communicate with the voices and tell them to go away. Question 13 (1 point) 6) Adam is prescribed: Risperidone 2mg to be titrated by 1-2mg every 24 hours to 4mg per day (then reassess) Benzotropine 1mg qHS Lorazepam 1-2mg q8h PRN for agitation/anxiety EVALUATE: What outcome would indicate that Adam is experiencing side effects or toxicity from the Risperidone? Question 13 options: Client demonstrates facial grimacing, muscle spasms of the tongue, face, neck and back within 72 hours of starting Resperidone. Client reports decreased frequency of hallucinations from 5-7 times per day to 1-3 times per day. Client demonstrates bradycardia, hypertension and dyspnea within 1-2 days of starting Resperidone. Hypothermia with temp less than 35.0 within 1-2 days of starting Resperidone. Question 14 (1 point) 7) EVALUATE: What is a desired outcome for Adam that suggests his medical and nursing treatment is effective? Question 14 options: Client demonstrates an increased number of negative symptoms of schizophrenia within 2 weeks. Client demonstrates reduced appetite and weight loss of 5 lbs in 1 month. Client demonstrates reduced frequency and intensity of hallucinations within 3 weeks. Client verbalizes beliefs that he is a valuable member of the FBI and is protecting the hospital within 1 month.