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A nurse in a mental health clinic is conducting a staff education session on schizophrenia. Which of the following manifestations should the nurse identify as negative symptoms? (Select all that apply.)
- A. Delusions
- B. Hallucinations
- C. Anhedonia
- D. Poor judgment
- E. Blunt affect
Correct Answer: C, E
Rationale: The correct manifestations for negative symptoms of schizophrenia are C: Anhedonia and E: Blunt affect. Anhedonia refers to the inability to feel pleasure, which is a common negative symptom. Blunt affect is a reduction in the range and intensity of emotional expression, another classic negative symptom. Delusions (A) and hallucinations (B) are positive symptoms involving distorted perceptions and beliefs. Poor judgment (D) is a cognitive symptom, not specific to schizophrenia. The absence of options F and G means they are not applicable to this question.
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A nurse in an emergency department is caring for a client who is experiencing acute alcohol withdrawal. Which of the following actions should the nurse take first?
- A. Implement seizure precautions.
- B. Insert an IV access site.
- C. Obtain a blood specimen.
Correct Answer: A
Rationale: The correct answer is A: Implement seizure precautions. The priority in caring for a client experiencing acute alcohol withdrawal is to prevent potential life-threatening complications like seizures. Implementing seizure precautions involves ensuring a safe environment, such as padding the bed and removing any harmful objects. This step takes precedence over inserting an IV access site (B) or obtaining a blood specimen (C) because seizures pose an immediate risk to the client's safety. It is crucial to address the most urgent need first to ensure the client's well-being.
A charge nurse is conducting a staff education in-service about depressive disorders. Which of the following should the nurse identify as a risk factor for depression?
- A. Being married
- B. Pregnancy
- C. Male gender
- D. Chronic illness
Correct Answer: D
Rationale: The correct answer is D: Chronic illness. Chronic illnesses can lead to feelings of hopelessness and helplessness, contributing to the development of depression. Individuals facing long-term health challenges may experience significant emotional distress, impacting their mental health. Other choices are incorrect because being married (A) can provide social support, which is protective against depression; pregnancy (B) can lead to mood changes but is not a consistent risk factor for depression; and male gender (C) does not inherently increase the risk of depression as much as other factors.
A nurse is admitting a client who is about to undergo surgery for benign prostatic hypertrophy. The client states, 'I don't know what I will do if they find I have cancer.' Which of the following responses should the nurse make?
- A. Why do you think you might have cancer when your diagnosis is a benign condition?'
- B. I'm looking at your chart here and I don't see any reason for you to worry about that.'
- C. I think that's something you need to discuss with your provider.'
- D. I'm hearing that you are concerned that it might turn out that you have cancer.'
Correct Answer: D
Rationale: Rationale: The correct response is D because it acknowledges the client's fear and validates their emotions. By reflecting back the client's statement, the nurse shows empathy and understanding. This approach helps build trust and rapport with the client, fostering open communication. Choice A is dismissive and does not address the client's feelings. Choice B is invalidating and can increase the client's anxiety. Choice C deflects the client's emotions instead of addressing them directly. In summary, option D is the best response as it demonstrates active listening and empathy, promoting a therapeutic nurse-client relationship.
A client who is about to undergo abdominal surgery states that he is very anxious about the operation. Which of the following responses should the nurse make?
- A. Ask him to describe what he is feeling.
- B. Give the client some reading material as a distraction.
- C. Suggest that he take a walk around the unit.
- D. Refer him to the pastoral care team.
Correct Answer: A
Rationale: The correct response is A: Ask him to describe what he is feeling. This option encourages the client to express his emotions, which can help alleviate anxiety by providing an outlet for his concerns. By actively listening and acknowledging his feelings, the nurse can establish trust and rapport, leading to better emotional support. Choice B may provide a temporary distraction but does not address the underlying anxiety. Choice C may be physically beneficial but does not address the client's emotional state. Choice D may be helpful for spiritual support but does not directly address the client's anxiety.
A nurse is caring for a client who is receiving treatment for alcohol withdrawal. Which of the following findings is the highest priority?
- A. Vitamin deficiency
- B. Diaphoresis
- C. Tremors
- D. Visual hallucinations
Correct Answer: D
Rationale: The correct answer is D: Visual hallucinations. Visual hallucinations in a client undergoing alcohol withdrawal indicate severe withdrawal symptoms and potential progression to delirium tremens, a life-threatening condition. Addressing visual hallucinations promptly is crucial to prevent harm or injury to the client. Vitamin deficiency (choice A), diaphoresis (choice B), and tremors (choice C) are common symptoms of alcohol withdrawal but are not as immediately life-threatening as visual hallucinations. Therefore, addressing visual hallucinations takes priority over these symptoms.