A patient has not come out of her room for breakfast. The nurse finds the patient moving restlessly about her room in a disorganized manner. The patient is talking to herself, and her verbal responses to the nurse are nonsensical and suggest disorientation. The nurse notices that the patient's skin is hot and dry, and her pupils are somewhat dilated. All these symptoms are significant departures from the patient's recent presentation. The patient is likely experiencing _____, and the nurse should _____.

Correct Answer: A

Rationale: The correct answer is A: anticholinergic toxicity. The patient is displaying symptoms such as restlessness, disorganized behavior, nonsensical verbal responses, disorientation, hot and dry skin, and dilated pupils, which are indicative of anticholinergic toxicity. Step-by-step rationale: 1. Restlessness and disorganized behavior are common symptoms of anticholinergic toxicity. 2. Nonsensical verbal responses and disorientation are also typical signs of anticholinergic toxicity. 3. Hot and dry skin can be caused by decreased sweating due to anticholinergic effects. 4. Dilated pupils are a classic sign of anticholinergic toxicity. 5. Checking vital signs and preparing to use a cooling blanket is the appropriate immediate action to manage anticholinergic toxicity. Summary of other choices: - B: Relapse of psychosis does not explain the physical symptoms like dilated pupils and hot/dry skin. - C: Neuroleptic malignant syndrome presents with

Correct Answer: B

Rationale: Step-by-step rationale for why answer B is correct: 1. Caffeine and nicotine are known to reduce the effectiveness of antipsychotic drugs. 2. Teaching patients and families about this can help them understand the importance of avoiding these substances. 3. By avoiding caffeine and nicotine, patients can improve the effectiveness of their treatment and reduce the risk of relapse. 4. This information empowers patients and families to make informed decisions to support treatment outcomes. Summary of why other choices are incorrect: A: Incorrect because relapse can occur due to various factors, not just medication non-adherence. C: Incorrect because relapse is a complex issue that may not be entirely prevented even with support, education, and adherence. D: Incorrect because education about medication side effects is still valuable, even if it may not entirely prevent relapse.

Correct Answer: A

Rationale: The correct answer is A: self-care deficit. This nursing diagnosis should be considered the priority because the patient is unable to attend to personal hygiene and has been lying in bed motionless and mute for 48 hours, indicating a significant impairment in self-care abilities. This is a critical issue that needs immediate attention to prevent further deterioration in the patient's physical and mental health. Choice B: situational low self-esteem is not the priority as the patient's current state is more indicative of physical neglect rather than a self-esteem issue. Choice C: disturbed thought processes may be a contributing factor to the patient's presentation, but the priority at this moment is addressing the self-care deficit to ensure the patient's safety and well-being. Choice D: impaired verbal communication, while important, is not the priority in this scenario as the patient's inability to communicate verbally is secondary to the urgent need for assistance with self-care.

Correct Answer: C

Rationale: The correct answer is C (12 months) because the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) requires symptoms to be present for at least 6 months before a diagnosis of schizophrenia can be made. This prolonged duration helps ensure that the symptoms are not due to temporary factors. Therefore, option C is the most appropriate choice. Options A (3 months), B (6 months), and D (18 months) do not align with the established diagnostic criteria for schizophrenia.

Correct Answer: B

Rationale: The correct answer is B because it acknowledges the individual's evolving perspective and empowers them to recognize positive changes post-separation. This approach helps the individual build confidence in their decision-making process and fosters self-awareness. Choice A focuses on past actions without addressing the current situation, Choice C uses a confrontational tone that may cause the individual to feel judged or defensive, and Choice D suggests a passive acceptance of returning to an abusive situation without promoting autonomy or self-efficacy.