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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.
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A nurse is caring for a client who has a new diagnosis of human immunodeficiency virus (HIV). He states, "I don't care what the doctors say, there is no way I can have HIV, and I don't need treatment for something I don't have." The nurse identifies that the client is experiencing which of the following types of crisis?
- A. Adventitious
- B. Internal
- C. Maturational
- D. Situational
Correct Answer: D
Rationale: The correct answer is D: Situational crisis. The client's denial of the HIV diagnosis and refusal of treatment indicate an acute crisis triggered by a specific event or situation - the new HIV diagnosis. In a situational crisis, individuals struggle to cope with a sudden and unexpected event, leading to cognitive dissonance and emotional distress. The client's disbelief and avoidance of the reality of the diagnosis demonstrate a maladaptive response to the crisis. Adventitious crisis (A) refers to events like natural disasters, which are not applicable here. Internal crisis (B) involves inner conflicts, not evident in this scenario. Maturational crisis (C) arises from developmental life stages, which is not the case here.
A nurse is sitting in the day room at an acute care mental health facility with a group of clients who are watching television. Suddenly, one of the clients jumps up screaming and runs out of the room. Which of the following actions should the nurse take?
- A. Ask the group what they think about the client’s behavior.
- B. Follow the client to determine the cause of the behavior.
- C. Ignore the incident because it is an attention-seeking behavior.
- D. Stay with the group and ask another client to check on the situation.
Correct Answer: B
Rationale: The correct answer is B: Follow the client to determine the cause of the behavior. This is the best course of action as the nurse should prioritize the safety and well-being of the client who exhibited distress. By following the client, the nurse can assess the situation, provide immediate assistance if needed, and ensure the client's safety. This proactive approach allows the nurse to address any potential risks or triggers that may have caused the client to react in such a manner.
Choice A is incorrect because seeking the group's opinion may waste time and delay necessary intervention. Choice C is incorrect as ignoring the incident could lead to a potentially dangerous situation being overlooked. Choice D is also incorrect as asking another client to check on the situation may not ensure the client's safety and well-being. The best approach is for the nurse to directly assess the client's needs and respond accordingly.
A charge nurse is admitting a client who has bipolar disorder and who is in the manic phase. Which of the following room assignments should the nurse give the client?
- A. A semi-private room across from the day room.
- B. A private room in a quiet location on the unit.
- C. A private room across from the exercise room.
- D. A semi-private room across from the snack area.
Correct Answer: B
Rationale: The correct answer is B: A private room in a quiet location on the unit. This choice minimizes stimuli and provides a calm environment, essential for managing manic symptoms. A quiet location reduces potential triggers for agitation or impulsivity. Semi-private rooms (A, D) may lead to conflicts with roommates. Rooms near common areas (C, D) can be noisy and disruptive. Overall, choice B promotes client safety and well-being during the manic phase.
A nurse is caring for a client who reports bilateral knee pain after hiking this past weekend in the mountains on rough ground. He says he is concerned because his cousin died from bone cancer recently. Which of the following actions should the nurse take?
- A. Tell the client that it is unlikely that he has bone cancer.
- B. Ask the client why he thinks the pain isn't a result of hiking.
- C. Suggest genetic testing so the client can understand his risks.
- D. Explain that the provider will see him and determine a course of action.
Correct Answer: D
Rationale: The nurse should provide reassurance while ensuring proper medical evaluation.
A nurse is making a home visit for a 16-year-old adolescent who attempted suicide. Which of the following behaviors should alert the nurse that the adolescent still has suicidal intent?
- A. Telling his parents that he doesn't want to talk about the suicide attempt.
- B. Stating that he wants to be with his peers more than with his parents.
- C. Preferring to eat his meals while watching TV.
- D. Planning to give his CD collection to his girlfriend.
Correct Answer: D
Rationale: The correct answer is D: Planning to give his CD collection to his girlfriend. This behavior indicates the adolescent is making future plans involving giving away possessions, which could be a sign of continued suicidal ideation. Giving away prized possessions is often seen as a way of saying goodbye or preparing for death. Choices A, B, and C do not necessarily indicate ongoing suicidal intent. A may suggest avoidance, B may indicate a desire for peer support, and C may be a personal preference. Therefore, D is the most concerning behavior that warrants immediate attention.