wife of a male client recently diagnosed with schizophrenia asks the nurse, "What exactly is schizophrenia? Is my husband all right?" Which response is
... [Show More] best for the nurse to provide to this family member?
A. It sounds like you're worried about your husband. Let's sit down and talk.
B. It is a chemical imbalance in the brain that causes disorganized thinking. Correct
C. Your husband will be just fine if he takes his medications regularly.
D. I think you should talk to your husband's psychologist about this question.
The nurse should answer the client's question with factual information and explain that schizophrenia is a chemical imbalance in the brain (B). (A) is a therapeutic response but does not answer the question, and may be an appropriate response after the nurse answers the question asked. Although (C) is likely true to some degree, it is also true that some clients continue to have disorganized thinking even with antipsychotic medications. Referring the spouse to the psychologist (D) is avoiding the issue; the nurse can and should answer the question.
8. A young adult male client, diagnosed with paranoid schizophrenia, believes that world is trying poison him. What intervention should the nurse include in this client's plan of care?
A. Remind the client that his suspicions are not true.
B. Ask one nurse to spend time with the client daily. Correct
C. Encourage the client to participate in group activities.
D. Assign the client to a room closest to the activity room.
A client with paranoid schizophrenia has difficulty with trust and developing a trusting relationship with one nurse (B) is likely to be therapeutic for this client. (A) is argumentative. Stress increases anxiety, and anxiety increases paranoid ideation; (C) would be too stressful and anxiety-promoting for a client who is experiencing pathological suspicions. (D) also might increase anxiety and stress.
9. The community health nurse talks to a male client who has bipolar disorder. The client explains that he sleeps 4 to 5 hours a night and is working with his partner to start two new businesses and build an empire. The client stopped taking his medications several days ago. What nursing problem has the highest priority?
A. Excessive work activity.
B. Decreased need for sleep.
C. Medication management. Correct
D. Inflated self-esteem.
The most important nursing problem is medication management (C) because compliance with the medication regimen will help prevent hospitalization. The client is also exhibiting signs of (A, B, and C); however, these problems do not have the priority of medication management.
10. A female client with obsessive-compulsive disorder (OCD) is describing her obsessions and compulsions and asks the nurse why these make her feel safer. What information should the nurse include in this client's teaching plan? (Select all that apply.)
A. Compulsions relieve anxiety. Correct
B. Anxiety is the key reason for OCD. Correct
C. Obsessions cause compulsions.
D. Obsessive thoughts are linked to levels of neurochemicals. Correct E. Antidepressant medications increase serotonin levels. Correct
Correct choices are (A, B, D, and E). To promote client understanding and compliance, the teaching plan should include explanations about the origin and treatment options of OCD symptomology. Compulsions are behaviors that help relieve anxiety (A), which is a vague feeling related to unknown fears, that motivate behavior (B) to help the client cope and feel secure. All obsessions (C) do not result in compulsive behavior. OCD is supported by the neurophysiology theory, which attributes a diminished level of neurochemicals (D), particularly serotonin, and responds to selective serotonin reuptake inhibitors (SSRI).
11. The nurse observes a female client with schizophrenia watching the news on TV. She begins to laugh softly and says, "Yes, my love, I'll do it." When the nurse questions the client about her comment she states, "The news commentator is my lover and he speaks to me each evening. Only I can understand what he says." What is the best response for the nurse to make?
A. What do you believe the news commentator said to you? Correct
B. Let's watch news on a different television channel.
C. Does the news commentator have plans to harm you or others?
D. The news commentator is not talking to you.
It is imperative that the nurse determine what the client believes she heard (A). The idea of reference may be to hurt herself or someone else, and the main function of a psychiatric nurse is to maintain safety. (B) is acceptable, but it is best to determine the client's beliefs. (C) is validating the idea of reference, while (D) is challenging the client.
12. A 40-year-old male client diagnosed with schizophrenia and alcohol dependence has not had any visitors or phone calls since admission. He reports he has no family that cares about him and was living on the streets prior to this admission. According to Erikson's theory of psychosocial development, which stage is the client in at this time?
A. Isolation.
B. Stagnation. Correct
C. Despair.
D. Role confusion.
The client is in Erikson's "Generativity vs. Stagnation" stage (age 24 to 45), and meeting the task includes maintaining intimate relationships and moving toward developing a family (B). (A) occurs in young adulthood (age 18 to 25), (C) occurs in maturity (age 45 to death), and (D)
occurs in adolescence (age 12 to 20). These are all stages that occur if individuals are not successfully coping with their psychosocial developmental stage.
13. The parents of a 14-year-old boy bring their son to the hospital. He is lethargic, but responsive. The mother states, "I think he took some of my pain pills." During initial assessment of the teenager, what information is most important for the nurse to obtain from the parents?
A. If he has seemed depressed recently.
B. If a drug overdose has ever occurred before.
C. If he might have taken any other drugs. Correct
D. If he has a desire to quit taking drugs.
Knowledge of all substances taken (C) will guide further treatment, such as administration of antagonists, so obtaining this information has the highest priority. (A and B) are also valuable in planning treatment. (D) is not appropriate during the acute management of a drug overdose.
14. A male client with mental illness and substance dependency tells the mental health nurse that he has started using illegal drugs again and wants to seek treatment. Since he has a dual diagnosis, which person is best for the nurse to refer this client to first?
A. The emergency room nurse.
B. His case manager. Correct
C. The clinic healthcare provider.
D. His support group sponsor.
The case manager (B) is responsible for coordinating community services, and since this client has a dual diagnosis, this is the best person to describe available treatment options. (A) is unnecessary, unless the client experiences behaviors that threaten his safety or the safety of others. (C and D) might also be useful, but it is most important at this time that a treatment program be coordinated to meet this client's needs.
15. A male client is admitted to a mental health unit on Friday afternoon and is very upset on Sunday because he has not had the opportunity to talk with the healthcare provider. Which response is best for the nurse to provide this client?
A. Let me call and leave a message for your healthcare provider. Correct
B. The healthcare provider should be here on Monday morning.
C. How can I help answer your questions?
D. What concerns do you have at this time?
It is best for the nurse to call the healthcare provider (A) because clients have the right to information about their treatment. Suggesting that the healthcare provider will be available the following day (B) does not provide immediate reassurance to the client. The nurse can also implement offer to assist the client (C and D), but the highest priority intervention is contacting the healthcare provider.
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