Nokea
A 45-year-old male client tells the nurse that he used to believe that he was Jesus Christ, but now he knows he is not. Which response is best for the nurse to make?
- A. Did you really believe you were Jesus Christ?
- B. I think you're getting well.
- C. Others have had similar thoughts when under stress.
- D. Why did you think you were Jesus Christ?
Correct Answer: C
Rationale: Choice C is the best response because it validates the client's experience by acknowledging that others have had similar thoughts when under stress. This response helps normalize the client's past experiences without judgment, fostering a supportive and empathetic environment. Choices A and D may come off as judgmental or confrontational, potentially making the client feel misunderstood or defensive. Choice B, 'I think you're getting well,' does not address the client's past belief or provide the understanding and validation that Choice C offers.
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A female client presents to the emergency center with confusion, emotional numbness, and expresses to the nurse a feeling of disbelief that she was raped. The nurse determines the client is in the acute phase of rape-trauma syndrome. What action should the nurse implement first?
- A. Secure samples of vaginal hair combings.
- B. Offer prophylactic antibiotic medication.
- C. Explain the rape protocol to the client.
- D. Implement crisis intervention counseling.
Correct Answer: C
Rationale: In cases of rape-trauma syndrome, it is crucial to provide clear information about what to expect during the examination and treatment. This can help the client regain a sense of control and reduce anxiety. Explaining the rape protocol to the client should be the first action to implement. Option A is not the priority at this stage as the immediate focus is on addressing the client's emotional needs and providing support. Option B is not the first action unless medically indicated. Option D, crisis intervention counseling, is important but should come after providing essential information and support to the client.
A client who is diagnosed with schizophrenia is admitted to the hospital. The nurse assesses the client's mental status. Which assessment finding is most characteristic of a client with schizophrenia?
- A. Mood swings.
- B. Extreme sadness.
- C. Manipulative behavior.
- D. Flat affect.
Correct Answer: D
Rationale: The correct answer is D: Flat affect. Flat affect, which is a lack of emotional expression, is highly characteristic of schizophrenia. Mood swings (choice A) are more indicative of mood disorders rather than schizophrenia. Extreme sadness (choice B) could be seen in depression but is not as specific to schizophrenia. Manipulative behavior (choice C) is not a defining characteristic of schizophrenia; it may be seen in various psychiatric conditions but is not the most characteristic feature of schizophrenia.
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.
- D. If he has a desire to quit taking drugs.
Correct Answer: C
Rationale: The correct answer is C. It's crucial to determine if the teenager might have taken other substances besides the pain pills mentioned by the mother. This information is vital for effective treatment because knowing the full scope of substances involved helps in managing potential interactions, side effects, and the overall condition of the patient. Options A, B, and D are not as critical in the immediate assessment compared to knowing if the teenager has ingested any other drugs.
A client with schizophrenia is experiencing auditory hallucinations that command him to harm himself. What is the nurse's priority action?
- A. Ensure the client is not left alone.
- B. Document the content of the hallucinations.
- C. Administer PRN antipsychotic medication.
- D. Encourage the client to ignore the voices.
Correct Answer: A
Rationale: The correct answer is to ensure the client is not left alone. When a client with schizophrenia is having auditory hallucinations that command self-harm, the priority is to ensure the client's safety. Leaving the client alone may increase the risk of self-harm. Documenting the content of the hallucinations (choice B) is important but not the priority when immediate safety is a concern. Administering PRN antipsychotic medication (choice C) may be necessary but is not the priority over ensuring the client's immediate safety. Encouraging the client to ignore the voices (choice D) is not as effective as ensuring the client's safety by being present and providing support.
The wife of a male client recently diagnosed with schizophrenia asks the nurse, 'What exactly is schizophrenia? Is my husband all right?' Which response is 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.
- 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.
Correct Answer: B
Rationale: The best response for the nurse to provide to the wife of the client diagnosed with schizophrenia is to offer factual information. Choice B is the correct answer as it explains that schizophrenia is a mental disorder characterized by a chemical imbalance in the brain that causes disorganized thinking. This response provides a simple and accurate explanation of the condition. Choices A, C, and D are incorrect because they do not directly address the wife's question about what schizophrenia is. Choice A focuses on emotional support rather than providing information about the disorder. Choice C gives false reassurance without addressing the nature of schizophrenia. Choice D deflects the question by suggesting the wife speak to the psychologist, missing an opportunity to educate and support the family member.