NCLEX-RN
Psychiatric Mental Health Nursing NCLEX RN Questions Questions
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The following scenario applies to the next 1 items
The behavioral health nurse is caring for a 28-year-old client
Item 1 of 1
Progress Notes
0914 – Nursing reports that the client required a PRN dose of diazepam after pacing the halls and shouting at the television despite failed redirect attempts.
Mental Status Exam – Alert and disoriented to person, place, and situation; fair eye contact; unkempt appearance. Thought process was disorganized and illogical. The client denied A/V hallucinations and suicidal ideations. + delusions; thoughts of persecution stating, ‘someone is out to get me’ while pointing to a television. Speech was disorganized, with a normal volume and a slightly increased rate. Insight and judgment are severely impaired.
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Based on the physician's progress note, the client is in which phase of schizophrenia?
Correct Answer: B
Rationale: Disorganized thoughts, delusions, and severe impairment indicate the acute phase of schizophrenia.
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