Nokea
A nurse is assessing a client diagnosed with schizophrenia. Which of the following behaviors should the nurse document to be associated with schizophrenia?
- A. Recurrent thoughts of past trauma
- B. Invents words that have no meaning
- C. Preoccupied with folding clothes
- D. Periods of elation with unusual talkativeness
Correct Answer: B
Rationale: The correct answer is B: Invents words that have no meaning. This behavior is associated with a symptom of schizophrenia called "neologisms," where individuals create new words that are not part of any known language. This is a characteristic feature of disorganized thinking in schizophrenia. Recurrent thoughts of past trauma (choice A) are more aligned with symptoms of PTSD rather than schizophrenia. Being preoccupied with folding clothes (choice C) is more indicative of obsessive-compulsive disorder. Periods of elation with unusual talkativeness (choice D) are more likely symptoms of bipolar disorder rather than schizophrenia.
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A client has made the decision to leave her alcoholic husband and reports feeling very depressed. Which of the following is a non-therapeutic statement by the nurse that demonstrates sympathy?
- A. You are feeling very depressed. I felt the same way when I decided to leave my husband.
- B. I can understand you are feeling depressed. It was a difficult decision. I'll sit with you.
- C. You seem depressed. It was a difficult decision to make. Would you like to talk about it?
- D. I know this is a difficult time for you. Would you like medication for anxiety?
Correct Answer: A
Rationale: The correct answer is A because the nurse is sharing her personal experience, which is not therapeutic as it shifts the focus from the client to the nurse's own experience. This can make the client feel unheard and invalidated. Choice B demonstrates empathy and offers support by acknowledging the client's feelings and offering to sit with them. Choice C also shows empathy and provides an opportunity for the client to talk. Choice D is non-therapeutic as it jumps to suggesting medication without exploring the client's emotions or needs.
A nurse is caring for a client who has late-stage Alzheimer's disease and is hospitalized for treatment of the flu. During the night shift,the client is found climbing into the bed of another client who becomes upset and scared. Which of the following actions should the nurse take?
- A. Medicate the patient with antipsychotics.
- B. Assist the client to the correct room.
- C. Move the client to a room at the end of the hall.
- D. Place the client in restraints.
Correct Answer: B
Rationale: The correct answer is B: Assist the client to the correct room. This is the appropriate action as it addresses the immediate issue of the client being in the wrong room, which is causing distress to the other client. Moving the client to the correct room ensures safety and comfort for both clients. Medicating with antipsychotics (choice A) is not the first-line intervention in this situation and should be avoided unless absolutely necessary due to potential side effects. Moving the client to a room at the end of the hall (choice C) may not address the underlying issue and can isolate the client unnecessarily. Placing the client in restraints (choice D) should be avoided as it can be traumatic and is not indicated in this scenario.
A nurse is caring for a client who has been diagnosed with end-stage liver cancer. The nurse recognizes that which of the following responses is an indication that the client is in the denial phase of the grief process?
- A. I can't believe the doctor graduated from medical school. He doesn't know a thing about treating cancer!
- B. Even though I am not hurting right now, I don't feel like I have the energy to get out of bed.
- C. The doctor says I only have a few months to live, but I know he is exaggerating to get me to take my medication.
- D. The doctor has been so good to me. I know he has tried everything he can. It's just my time.
Correct Answer: C
Rationale: The correct answer is C. In this response, the client is demonstrating denial by refusing to accept the doctor's prognosis of having only a few months to live. This indicates an inability to acknowledge the severity of the situation, a common characteristic of the denial phase in the grief process. The client's belief that the doctor is exaggerating shows a defense mechanism to cope with the overwhelming truth. Options A, B, and D do not exemplify denial. Option A shows anger, Option B indicates depression, and Option D reflects acceptance and resignation, which are not characteristics of denial in the grief process.
A nurse is talking with the guardian of a school-aged child recently diagnosed with intermittent explosive disorder (IED). The guardian says,My child is impulsive, acts out aggressively, and then seems pleased with themselves. How can my child be happy? Which of the following responses should the nurse make?
- A. Appearing pleased after an aggressive or impulsive act has not been directly linked to intermittent explosive disorder.
- B. Appearing pleased after an aggressive or impulsive act can be a sense of relief rather than being happy.
- C. Appearing pleased after an aggressive or impulsive act is a manifestation of lack of empathy or compassion.
- D. Appearing pleased after an aggressive or impulsive act is within the control of your child.
Correct Answer: B
Rationale: Correct Answer: B
Rationale: The nurse should choose response B because it addresses the guardian's concern accurately. Individuals with intermittent explosive disorder may experience a sense of relief rather than genuine happiness after acting out aggressively. This relief can stem from a temporary release of pent-up emotions or stress. It is important for the nurse to clarify this distinction to the guardian to help them understand their child's behavior better and guide appropriate interventions.
Incorrect Choices:
A: This response dismisses the guardian's observations and does not provide a helpful explanation.
C: This response inaccurately suggests a lack of empathy or compassion, which is not a defining characteristic of intermittent explosive disorder.
D: This response implies that the behavior is under the child's control, which is not necessarily the case with impulsive disorders like IED.
A nurse is leading a group therapy session for clients who are newly diagnosed with cancer. Which of the following statements should be an appropriate response by the nurse?
- A. Let's discuss what you mean when you say that you cannot ever return to work.
- B. You need to work hard on resolving conflict with those closest to you.
- C. Antidepressants are not your solution, but this therapy group is.
- D. I notice you keep clenching your fists. Why are you doing this?
Correct Answer: A
Rationale: Correct Answer: A
Rationale: Option A demonstrates active listening and encourages further exploration of the client's feelings and perspectives. It shows empathy and promotes open communication. It allows the nurse to understand the client's concerns about returning to work and address them effectively.
Summary:
B: This choice is not appropriate as it focuses on resolving interpersonal conflicts rather than addressing the client's concerns about their diagnosis.
C: This choice dismisses the potential need for medication and minimizes the importance of therapeutic support.
D: This choice addresses a physical behavior without directly addressing the client's emotional concerns about work.