Nokea
A nurse in a mental health facility is collecting a blood specimen from a client. The client is hallucinating and states
- A. That looks like a snake
- B. and I won't let it take all of my blood.' Which of the following responses should the nurse make?
- C. I don’t see a snake, but that must be scary for you.
- D. I’m using a syringe to obtain your blood, not a snake.
- E. Your provider requires this blood specimen.
- F. You must be mistaken.
Correct Answer: A
Rationale: Acknowledging the client's fear and providing reassurance without confirming the hallucination helps build trust and reduce anxiety. This empathetic response supports the client’s emotional state.
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A nurse in a substance use disorder clinic is explaining the alcohol recovery process to a client's family. Which of the following should the nurse identify as the first step toward successful recovery from alcohol use disorder?
- A. Form a close support network.
- B. Acknowledge an inability to control drinking.
- C. Incorporate a form of spirituality into daily life.
- D. Agree to a prescription for an alcohol use deterrent.
Correct Answer: B
Rationale: Acknowledging an inability to control drinking is crucial as it represents acceptance of the problem. Without this self-awareness, the individual is unlikely to seek or benefit from treatment options. This step is foundational, preceding the use of support networks, spirituality, or medication.
A nurse is collecting data from a client who has antisocial personality disorder. Which of the following findings should the nurse expect?
- A. Preoccupation with details.
- B. Manipulative behaviors.
- C. Impulsiveness.
- D. Splitting.
Correct Answer: B
Rationale: Manipulative behaviors are a common finding in individuals with antisocial personality disorder. These individuals often use manipulation to gain control or achieve their own goals without regard for others, aligning with the disorder’s characteristics.
A nurse is collecting data from a client who has schizophrenia. Which of the following client statements indicates that the client is experiencing a command hallucination?
- A. Can you see these spiders crawling all over me?
- B. The aliens are going to abduct me tonight.
- C. Are you planning to kill me?
- D. The voices told me to quit eating the food here.
Correct Answer: D
Rationale: The statement 'The voices told me to quit eating the food here' is indicative of a command hallucination, where the client hears voices instructing them to take specific actions. This distinguishes it from visual hallucinations or delusions.
A nurse is caring for a client who has an anxiety disorder. The client transforms their anxiety into physical manifestations. The nurse should recognize that the client is exhibiting which of the following manifestations?
- A. Reaction formation.
- B. Somatization.
- C. Sublimation.
- D. Intellectualization.
Correct Answer: B
Rationale: Somatization involves the transformation of anxiety into physical symptoms, such as pain or fatigue, without a medical cause. This is a way the body expresses psychological distress through physical symptoms, aligning with the client’s behavior.
A nurse is collecting data from a client who has anorexia nervosa. Which of the following findings should the nurse expect?
- A. Cold extremities.
- B. Diarrhea.
- C. Tooth erosion.
- D. Lanugo.
Correct Answer: A,C,D
Rationale: Cold extremities, tooth erosion, and lanugo are common in anorexia nervosa. Poor circulation causes cold extremities, vomiting erodes teeth, and lanugo grows to conserve heat due to fat loss, reflecting the disorder’s physical impact.