The nurse is caring for a client with schizophrenia. Which of the following outcomes is
the least desirable?
A) The client spends more time by
... [Show More] himself
B) The client doesn't engage in delusional thinking
C) The client doesn't harm himself or others
D) The client demonstrates ability to meet his own self-care needs
The client with schizophrenia is commonly socially isolated and withdrawn; therefore, having the
client spend more time by himself wouldn't be a desirable outcome. Rather, a desirable
outcome would specify that the client spend more time with other clients and staff on the unit.
Delusions are false personal beliefs. Reducing or eliminating delusional thinking using talking
therapy and antipsychotic medications would be a desirable outcome. Protecting the client and
others from harm is a desirable client outcome achieved by close observation, removing any
dangerous objects, and administering medications. Because the client with schizophrenia may
have difficulty meeting his or her own self-care needs, fostering the ability to perform self-care
independently is a desirable client outcome.
The nurse formulates a nursing diagnosis of Impaired verbal communication for a client
with schizotypal personality disorder. Based on this nursing diagnosis, which nursing
intervention is most appropriate?
A) Helping the client to participate in social interactions
B) Establishing a one-on-one relationship with the client
C) Establishing alternative forms of communication
D) Allowing the client to decide when he wants to participate in verbal communication with the nurse.
By establishing a one-on-one relationship, the nurse helps the client learn how to interact with people in
new situations. The other options are appropriate but should take place only after the nurse-client
relationship is established
Since admission 4 days ago, a client has refused to take a shower, stating, "There are
poison crystals hidden in the showerhead. They'll kill me if I take a shower." Which
nursing action is most appropriate?
A) Dismantling the showerhead and showing the client that there is nothing in it
B) Explaining that other clients are complaining about the client's body odor C)
Asking a security officer to assist in giving the client a shower
D) Accepting these fears and allowing the client to take a sponge bath
By acknowledging the client's fears, the nurse can arrange to meet the client's hygiene needs in
another way. Because these fears are real to the client, providing a demonstration of reality (as in
option A) wouldn't be effective at this time. Options B and C would violate the client's rights by
shaming or embarrassing the client.
Sharing a benign, nonthreatening, personal fact or feeling helps the nurse establish rapport and
encourages the client to confide in the nurse. The nurse can't know how the client feels. Telling
the client otherwise, as in option B, would justify the suspicions of a paranoid client; furthermore,
the client relies on the nurse to interpret reality. Option C is incorrect because it focuses on the
nurse's feelings, not the client's. Option D wouldn't help establish rapport or encourage the client
to confide in the nurse.
How soon after chlorpromazine (Thorazine) administration should the nurse expect to see a client's
delusional thoughts and hallucinations eliminated?
Drug therapy with thioridazine (Mellaril) shouldn't exceed a daily dose of 800 mg to prevent which adverse reaction?
A) Hypertension
B) Respiratory arrest
C) Tourette Syndrome
D) Retinal pigmentation
Retinal pigmentation may occur if the thioridazine dosage exceeds 800 mg per day. The
other options
don't occur as a result of exceeding this dose
A nurse is talking with a client in an acute mental health facility who has a new diagnosis of chronic
kidney disease. Which of the following statements by the client should the nurse identify as an
indication of anticipatory grieving?
"I just can't believe that this dialysis is going to ruin my whole life."
An adolescent female in an acute mental health facility has attention deficit hyperactivity disorder
(ADHD). The nurse should expect which of the following findings?
Impulsivity
A school-age child with ADHD is being discharged from an acute mental health facility. The nurse is
teaching the parents about atomoxetine. Which of the following instructions should the nurse include
in the teaching?
"Give the dose in the morning to help prevent insomnia."
A nurse is planning care for a child in an acute mental health facility who has autism spectrum
disorder. Which of the following interventions should the nurse include in the plan of care?
Establish a reward system for positive behavior.
A depressed patient says, "Nothing matters anymore." What is the most appropriate
response by the nurse?:
1. "Are you having thoughts of suicide?"
2. "I am not sure I understand what you are trying to say."
3. "Try to stay hopeful. Things have a way of working out."
4. "Tell me more about what interested you before you became depressed." [Show Less]