Nokea
A male client with schizophrenia tells the nurse that the FBI is monitoring his phone calls. What is the nurse's best response?
- A. Let's talk about your feelings of being monitored.
- B. There is no evidence that the FBI is monitoring your calls.
- C. Why do you think the FBI is interested in your phone calls?
- D. I can assure you that your phone calls are not being monitored.
Correct Answer: A
Rationale: The correct response is to choose A: 'Let's talk about your feelings of being monitored.' This response shows empathy and encourages the client to express his feelings. Engaging the client in a discussion about his feelings can help address underlying fears without directly challenging the delusion. Choice B is incorrect because directly denying the delusion may lead to increased distrust or agitation in the client. Choice C may come across as confrontational, which can exacerbate the client's paranoia. Choice D offers a false sense of assurance and does not address the client's concerns effectively.
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Several clients with chronic mental illness and multiple substance abuse histories live in a group residential home and attend a daycare mental health facility where group and individual therapies are provided. The RN finds the common bathroom at the facility with sputum on the walls, urine in the sink and on the floors, and the toilet stopped up with tissue, paper towels, and feces. What is the priority issue that the RN should address?
- A. Medication non-compliance.
- B. Number of bathroom facilities.
- C. Infection control.
- D. Acting out behaviors.
Correct Answer: C
Rationale: The priority issue that the RN should address is infection control. The unsanitary conditions in the bathroom, with sputum on the walls, urine in the sink and on the floors, and the toilet clogged with tissue, paper towels, and feces, pose a significant health risk to all residents and staff. Addressing infection control is crucial to prevent the spread of diseases and ensure the well-being of everyone in the facility. Medication non-compliance is important but not the priority in this situation. The number of bathroom facilities, while relevant, is not the immediate concern when faced with unsanitary conditions. Acting out behaviors, though a valid concern in mental health settings, are not the priority when faced with such unsanitary and potentially infectious conditions.
An anxious client expressing a fear of people and open places is admitted to the psychiatric unit. What is the most effective way for the nurse to assist this client?
- A. Plan an outing within the second week of admission.
- B. Distract the client whenever they express discomfort about being with others.
- C. Confront the client's fears and discuss the possible causes of these fears.
- D. Accompany the client outside for an increasing amount of time each day.
Correct Answer: D
Rationale: The most effective way to assist a client with a fear of people and open places is through gradual desensitization by controlled exposure to the situation which is feared (D). This method helps the client confront their fears in a safe and supportive manner, allowing them to gradually build confidence and reduce anxiety. Planning an outing within the second week of admission (A) may be too soon and overwhelming for the client. Distracting the client whenever they express discomfort (B) does not address the underlying issue and may promote denial. Confronting the client's fears and discussing possible causes (C) could be too aggressive initially and may not be well-tolerated by the client.
The LPN/LVN is caring for a client with schizophrenia who is experiencing auditory hallucinations. Which intervention is most appropriate?
- A. Encourage the client to focus on reality-based activities.
- B. Ask the client to describe the voices he hears.
- C. Tell the client that the voices are not real.
- D. Encourage the client to interact with others who are not experiencing hallucinations.
Correct Answer: B
Rationale: Asking the client to describe the voices he hears is the most appropriate intervention in this situation. It helps the nurse assess the content and severity of the hallucinations, enabling the planning of appropriate interventions. Choice A is not as effective as directly addressing the hallucinations. Choice C may lead to mistrust as the client believes the voices are real. Choice D does not address the client's immediate need related to the hallucinations.
A client with schizophrenia is being treated with haloperidol (Haldol). The client reports feeling restless and unable to sit still. What should the nurse do first?
- A. Instruct the client to take deep breaths and relax.
- B. Assess the client for signs of akathisia.
- C. Encourage the client to engage in physical activity.
- D. Administer a PRN dose of lorazepam (Ativan).
Correct Answer: B
Rationale: Restlessness and inability to sit still are signs of akathisia, an extrapyramidal side effect of antipsychotic medications. The nurse should first assess the client for signs of akathisia by observing their movements and behavior. Assessing for akathisia is crucial to differentiate it from other conditions and to intervene appropriately. Instructing the client to relax or engage in physical activity may not address the underlying issue of akathisia. Administering lorazepam should not be the first action as it may mask the symptoms of akathisia temporarily without addressing the root cause.
A 45-year-old female client is admitted to the psychiatric unit for evaluation. Her husband states that she has been reluctant to leave home for the last six months. The client has not gone to work for a month and has been terminated from her job. She has not left the house since that time. This client is displaying symptoms of which disorder?
- A. Claustrophobia.
- B. Acrophobia.
- C. Agoraphobia.
- D. Necrophobia.
Correct Answer: C
Rationale: The correct answer is C, Agoraphobia. Agoraphobia involves the fear of situations where escape might be difficult, often leading to the individual avoiding public spaces or leaving their home. In this case, the client's reluctance to leave home, not going to work, and staying indoors for an extended period align with the symptoms of agoraphobia. Choices A, B, and D are incorrect. Claustrophobia is the fear of confined spaces, acrophobia is the fear of heights, and necrophobia is the fear of death or dead things, none of which are consistent with the client's symptoms described in the scenario.