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A client is admitted to the psychiatric unit with a diagnosis of schizophrenia. The client verbalizes to the nurse, 'Someone wants to kill me tonight.' Which response by the nurse is best?
- A. No one wants to kill you.
- B. Why do you think that?
- C. They don't know you are hospitalized, so you are safe.
- D. It must feel frightening to think someone wants to hurt you.
Correct Answer: D
Rationale: Acknowledging the client’s fear validates their emotions and builds trust without reinforcing delusions. Denying the belief, questioning, or reassuring about safety may escalate agitation or distrust in a client with schizophrenia.
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The nurse is caring for a client diagnosed with acute pulmonary edema. Which psychosocial strategy should the nurse plan to incorporate into the care of the client?
- A. Reducing anxiety
- B. Increasing fluid volume
- C. Decreasing cardiac output
- D. Promoting a positive body image
Correct Answer: A
Rationale: Reducing anxiety will help the client during treatment to increase cardiac output and decrease fluid volume. When cardiac output falls as a result of acute pulmonary edema, the sympathetic nervous system is stimulated. Stimulation of the sympathetic nervous system results in the fight-or-flight reaction, which further impairs cardiac function. A disturbed body image is not a common problem among clients with acute pulmonary edema.
The mental health nurse is caring for a client with Cluster B personality disorder. The nurse would expect the client to exhibit which behaviors? Select all that apply.
- A. suspicious of others, magical thinking, eccentric behavior, paranoia, relationship deficits
- B. preoccupation with rules and details, hoarding, ritualistic behavior, extremely devoted to work
- C. easily bored, poor and shallow interpersonal relationships, enjoys being the center of attention
- D. impulsivity, unpredictable behavior, extreme mood shifts, easily angered, playing people against each other
- E. suspicious and untrusting of others, argumentative, controlling of others, thoughts of grandiosity
Correct Answer: C,D
Rationale: Cluster B personality disorders (e.g., histrionic, borderline) involve being easily bored, shallow relationships, attention-seeking (C), and impulsivity, mood shifts, and manipulative behavior (D). Options A and E describe Cluster A, and B describes Cluster C.
A client is about to undergo a pericardiocentesis to help manage rapidly accumulating pericardial effusion. What is the best plan for the nurse to implement to alleviate the client's apprehension?
- A. Suggesting the client watch television during the procedure as a distraction
- B. Talking to the client from the foot of the bed and assisting with the procedure
- C. Staying beside the client to give information and encouragement during the procedure
- D. Assuring the client that even though there are other clients needing care, the client's needs are most important
Correct Answer: C
Rationale: Clients who develop sudden complications are in situational crisis and need therapeutic intervention. Staying with the client and giving information and encouragement is part of building and maintaining trust in the nurse-client relationship. Options 1 and 4 distance the nurse from the client psychosocially. The nurse should ask another caregiver to be available to assist with the procedure.
The nurse admits an older adult client to the unit. The client demonstrates decreased ability to problem-solve, psychomotor deficits, and social isolation. Which nursing action is most appropriate?
- A. Prepare a schedule of activities and monitor the client's participation in the activities.
- B. Encourage the client to choose the client's own activities.
- C. Allow the client time to get acclimated to the milieu before scheduling activities.
- D. Allow the client to rest quietly to restore energy level.
Correct Answer: C
Rationale: Allowing time to acclimate helps the client adjust to the new environment, reducing stress and supporting engagement, especially given their cognitive and social challenges. Scheduling activities or encouraging choices may be premature, and rest alone does not address isolation.
The nurse is caring for a client who has been diagnosed with terminal pancreatic cancer. The family is asking what to expect when the end draws near. Which response by the nurse is most appropriate?
- A. I will have the doctor talk to you about that.
- B. The hospice nurse is the best person to answer your questions. I can put in a consult for you.
- C. Don't worry about that right now. You don't know if there is another treatment option that will work.
- D. I can tell you what to look for when the time comes. In the meantime, what are your wishes and goals for care?
Correct Answer: D
Rationale: This response addresses the family's question while opening a discussion about care goals, which is supportive and appropriate.