A client with many positive symptoms of schizophrenia whose ...

[burchfield96]

A client with many positive symptoms of schizophrenia whose behavior is disorganized and who is
  highly anxious tells the nurse in the psychiatric emergency department You have got to help me. I
  do not know what is going on.
 
  I think someone is trying to wipe me out. I have to get a gun.. The
  client, a college student, lives alone and has no family or support system in the immediate area. He
  has not left his room in 2 weeks, has not eaten in several days, and is unkempt. Of the available
  treatment settings, the nurse should recommend
  a. acute hospitalization for 4 to 5 days.
  b. partial hospitalization for 2 weeks.
  c. day treatment for 4 weeks.
  d. home treatment for 6 weeks.

Question 2

During an episode of acute mania a newly admitted client who is displaying hyperactive, restless,
  and disorganized behavior goes into the dining room and begins to throw food and dishes.
 
  Verbal
  intervention is ineffective and seclusion is instituted. The items of documentation that should be
  included in the medical record include (more than one answer may be correct)
  A. 1750: Client entered dining room and began to shout and randomly throw food and dishes at
  walls and other clients.
  B. Continued to throw items despite limit setting and verbal redirection. Client refused to leave
  dining room.
  C. Client's behavior determined to pose a substantial risk of harm to others. Client escorted to
  seclusion without a struggle by four staff.
  D. Seclusion explained. Harmful items removed from room and person per unit protocol.
  E. 1800: prn lorazepam (Ativan) administered IM.
  F. 1815: Vital signs: blood pressure, 120/85 mm Hg; pulse, 90 beats/min; respirations, 22
  breaths/min. Client lying on mattress. Chanting profanity.

[moormoney]

Answer to Question 1

A
A short-term hospital stay would probably serve the client best. Medication can be started, the
inpatient milieu can provide structure, observation can be ongoing, interpersonal support can be
provided, physical needs can be met, and the safety of client and others preserved. The client has no
support system to provide care at home, and both partial hospitalization and day treatment would
leave the client without structure and support for at least 12 hours daily.

Answer to Question 2

A, B, C, D, E, F
Rationale: All items should be included in the medical record. Options A and B provide essential
information explaining the client's behavior and need for the environmental simplification provided
by seclusion. Option C provides a rationale for seclusion and describes the process of secluding the
client. Option D reiterates elements of the agency protocol designed to support client psychosocial
and biophysical safety. Option E documents medication administration. Option F documents client
physical status and behavior.