The nurse finds a client crying in his room. The client states, "I'm so sad and lonely. I'm sitting here crying
like a baby." The nurse's best response
... [Show More] is:
a. "I think you are a fine man".
b. "Why don't you get involved in the activity group?"
c. "It's a gray rainy day. That's why you feel down. Everyone is down today."
d. "Are you embarrassed because you're crying?" - Correct Answer: d. "Are you embarrassed because
you're crying?"
A withdrawn client is assessed as having distorted thinking that is not reality based. A nursing diagnosis
that should be considered for her would be
a. impaired verbal communication.
b. disturbed thought processes.
c. disturbed self-esteem.
d. defensive coping. - Correct Answer: b. disturbed thought processes
Jim is sometimes seen moving his lips silently or murmuring to himself when he does not realize others
are watching. Sometimes when he is conversing with others, he suddenly stops, appears distracted for a
moment, and then resumes. Based on these observations, Jim most likely is experiencing which
symptom(s)? Select all that apply:
a. Illusions.
b. Paranoia.
c. Delusional thinking.
d. Auditory hallucinations.
e. Impaired reality testing.
f. Stereotyped behaviors. - Correct Answer: d. Auditory hallucinations.
e. Impaired reality testing.
Looseness of associations in a person with schizophrenia indicate
a. paranoia.
b. mood instability.
c. depersonalization.
d. poorly organized thinking. - Correct Answer: d. poorly organized thinking.
Which assessment finding represents a negative symptom ofschizophrenia?
a. Apathy
b. Delusion
c. Motortic
d. Hallucination - Correct Answer: a. Apathy
In general, when a nurse admitting a client experiencing an acute schizophrenia episode, she would most
likely assess which of the following?
a. Open and outgoing personality
b. Loss of contact with reality
c. Feelings of guilt and worthlessness
d. Logical and precise thinking - Correct Answer: b. Loss of contact with reality
While the nurse was doing the assessment, Jeffery turned to an empty chair talking as if someone was
sitting there. The nurse was unable to understand what he was mumbling. This, in fact, indicatesthat the
patient has: [Show Less]