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A client with schizophrenia is admitted to the inpatient mental health unit. When asked her name, she responds, 'I am Elizabeth, the Queen of England.' Which should the nurse recognize this client's statement is indicating?
- A. Visual illusion
- B. Loose association
- C. Grandiose delusion
- D. Auditory hallucination
Correct Answer: C
Rationale: A delusion is an important personal belief that is almost certainly not true and that resists modification. An illusion is a misperception or misinterpretation of externally real stimuli. Loose association is thinking that is characterized by speech in which ideas that are unrelated shift from one subject to another. A hallucination is a false perception.
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A 28-year-old woman is recovering from her third consecutive spontaneous abortion in 2 years. Which is the most therapeutic nursing intervention for this client at her follow-up appointment?
- A. Focusing on the client's physical needs
- B. Encouraging the client to verbalize her feelings about the loss
- C. Reminding the client that she will be able to become pregnant again
- D. Encouraging the client to think of herself, her husband, and their future
Correct Answer: B
Rationale: The most therapeutic nursing intervention for a client recovering from multiple spontaneous abortions is to encourage the client to verbalize her feelings about the loss. This allows the client to express and process her emotions, facilitating the grieving process and emotional healing. Focusing solely on the client's physical needs, as in choice A, overlooks the importance of addressing the emotional aspect of the client's experience. Choice C, reminding the client that she will be able to become pregnant again, fails to acknowledge the current loss and may minimize the client's feelings of grief. Choice D, encouraging the client to think of herself, her husband, and their future, does not directly address the client's immediate emotional needs related to the recent loss. Therefore, choice B is the most appropriate intervention to support the client in coping with her emotional distress.
For a client with obsessive-compulsive disorder, which reaction is most likely to occur when the performance of a ritual is interrupted?
- A. Anxiety
- B. Hostility
- C. Aggression
- D. Withdrawal
Correct Answer: A
Rationale: When a client with obsessive-compulsive disorder is interrupted while performing a ritual, the most likely reaction is anxiety. The compulsive ritual serves as a coping mechanism to control anxiety, so any disruption to this ritual can heighten the individual's anxiety levels. Hostility is typically part of the disorder itself and not a direct reaction to the interruption of the ritual. Aggression may occur only if anxiety escalates to a panic level, leading to overt anger expression. Withdrawal is not a common behavioral pattern associated with obsessive-compulsive disorder and is not a typical reaction to ritual interruption.
A community health nurse visits a recently widowed retired military client. When the nurse visits, the ordinarily immaculate house is in chaos, and the client is disheveled and has an alcohol type of odor on his breath. Which therapeutic statement should the nurse make to the client?
- A. I can see this isn't a good time to visit.
- B. You seem to be having a very troubling time.
- C. Do you think your wife would want you to behave like this?
- D. What are you doing? How much are you drinking and for how long?
Correct Answer: B
Rationale: The therapeutic statement is the one that helps the client explore his situation and express his feelings. Reflection, by telling the client that the nurse feels that he is experiencing a troubled or difficult time, is empathic, and it will assist the client with beginning to ventilate his feelings. Option 1 uses humor to avoid therapeutic intimacy and effective problem-solving. Option 3 uses admonishment and tries to shame the client, which is not therapeutic or professional. This social communication belittles the client, will likely cause anger, and may evoke 'acting out' by the client. Option 4 uses social communication.
A nurse is caring for a client with agoraphobia. Which signs and symptoms would the nurse anticipate? Select all that apply.
- A. panic attacks
- B. impaired short-term memory
- C. auditory hallucinations
- D. inability to leave home
Correct Answer: A,D
Rationale: Agoraphobia involves panic attacks and fear of leaving safe environments, leading to inability to leave home. Memory issues and hallucinations are not typical.
The nurse notes that a toddler has numerous bruises, a possible fractured left humerus, and several lacerations. Which action will the nurse take first?
- A. Report findings to Child Protective Services.
- B. Ask the parents what caused the injuries.
- C. Review the client's previous medical record.
- D. Observe the interaction between the parents and client.
Correct Answer: A
Rationale: Suspected child abuse, indicated by multiple bruises, a possible fracture, and lacerations, requires immediate reporting to Child Protective Services as mandated by law to ensure the child's safety. This takes precedence over other actions to initiate protective measures promptly.