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A nurse in a hospital is caring for a client who has agoraphobia. Which of the following statements by the client indicates understanding of the goals of treatment?
- A. "I plan to sit on a park bench for a few minutes each day."
- B. "I can try participating in group therapy every week."
- C. "I will join a book club in my neighborhood."
- D. "I should avoid entering elevators and other closed spaces."
Correct Answer: A
Rationale: The correct answer is A: "I plan to sit on a park bench for a few minutes each day." This statement indicates the client's understanding of gradual exposure therapy, a common treatment for agoraphobia. Exposure to feared situations in a controlled manner helps desensitize the client to their anxiety triggers. Sitting on a park bench signifies a small step towards facing the fear of open spaces. Choices B, C, and D do not directly address the core issue of agoraphobia or the specific treatment approach. Group therapy and joining a book club may be beneficial but do not target the fear of open spaces. Avoiding elevators and closed spaces is a safety behavior that reinforces the fear and hinders recovery.
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A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse identify as a negative symptom?
- A. Delusions
- B. Hallucinations
- C. Social withdrawal
- D. Agitation
- E. Flat affect
Correct Answer: C
Rationale: The correct answer is C: Social withdrawal. Negative symptoms in schizophrenia involve the absence or reduction of normal behaviors or functions. Social withdrawal is a common negative symptom, characterized by the client's lack of interest in social interactions. Delusions (A) and hallucinations (B) are positive symptoms, involving the presence of abnormal behaviors or perceptions. Agitation (D) is a symptom of increased motor activity, not a negative symptom. Flat affect (E) refers to a lack of emotional expression, which is also a negative symptom. In summary, social withdrawal aligns with the definition of negative symptoms in schizophrenia, making it the correct answer.
A nurse is caring for a client who has schizophrenia and is experiencing a variety of hallucinations. Which of the following hallucinations is the priority for the nurse to address?
- A. Visual hallucination
- B. Gustatory hallucination
- C. Command hallucination
- D. Tactile hallucination
Correct Answer: C
Rationale: The correct answer is C: Command hallucination. This is the priority because command hallucinations can pose a direct threat to the client or others if the commands are harmful or dangerous. Addressing command hallucinations promptly is crucial to ensure the safety of the client and those around them. Visual hallucinations (A) may not necessarily lead to immediate harm. Gustatory hallucinations (B) involve taste sensations and are not typically associated with imminent danger. Tactile hallucinations (D) involve false perceptions of touch and are also less likely to result in immediate harm compared to command hallucinations.
A nurse is assessing a client who has a diagnosis of conversion disorder. Which of the following is an expected finding?
- A. Frequent manic episodes.
- B. Refusal of medication due to paranoia.
- C. Preoccupation with manifestations of various illnesses.
- D. Involuntary loss of a sensory function.
Correct Answer: D
Rationale: The correct answer is D: Involuntary loss of a sensory function. In conversion disorder, physical symptoms are present without a known medical cause. This can manifest as sensory deficits such as blindness or paralysis. This finding is expected as it is a hallmark of conversion disorder. Manic episodes (A) are more indicative of bipolar disorder, medication refusal due to paranoia (B) may be seen in conditions like schizophrenia, and preoccupation with various illnesses (C) is characteristic of somatic symptom disorder. Therefore, the correct choice is D as it aligns with the presentation of conversion disorder.
A nurse is assigning a room to a client who is experiencing a manic episode. Which of the following is the most appropriate room selection?
- A. A room adjacent to the nursing station
- B. A room without a window
- C. A room with dim lighting
- D. A room containing personal belongings
Correct Answer: A
Rationale: A room close to the nursing station allows for close monitoring and quick intervention if necessary.
A nurse is assessing a client who has schizophrenia. The client says, "I hear voices telling me what to do." This is an example of which of the following?
- A. Delusional disorder
- B. Associative looseness
- C. Hallucination
- D. Anhedonia
Correct Answer: C
Rationale: Auditory hallucinations are common in schizophrenia, involving hearing voices that are not real.