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A nurse is caring for a client who has been diagnosed with schizoaffective disorder. The client states, 'I am the president of the United States.' Which of the following responses should the nurse make?
- A. You are not the president. You are a client in the hospital.
- B. Tell me more about being the president.
- C. Why do you think you are the president?
- D. Let's talk about something else.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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A client has been diagnosed with paranoid personality disorder. Which of the following behaviors should the nurse expect?
- A. Distrust of others
- B. Reluctance to confide in others
- C. Suspiciousness of others
- D. Jealousy of others
Correct Answer: A
Rationale: Individuals with paranoid personality disorder commonly display a pervasive distrust of others. They often interpret benign actions of others as hostile or malicious, leading to suspicion and a belief that others have malevolent intentions. While choices B, C, and D may be present in individuals with different personality disorders or issues, distrust of others is a hallmark feature of paranoid personality disorder, making it the correct behavior to expect in these clients.
Which of the following are therapeutic communication techniques that a healthcare provider can use when interacting with clients? Select one that does not apply.
- A. Using Noise
- B. Offering self
- C. Giving advice
- D. Providing reassurance
Correct Answer: C
Rationale: Therapeutic communication techniques aim to promote a therapeutic relationship and client well-being. Using noise is a non-therapeutic technique that can hinder effective communication. Offering self, providing reassurance, and using silence are considered therapeutic. However, giving advice is often seen as non-therapeutic as it can diminish client autonomy and hinder problem-solving skills.
During an acute panic attack, which intervention should the nurse implement?
- A. Encourage the client to discuss their feelings
- B. Provide a calm environment
- C. Teach the client deep breathing exercises
- D. Leave the client alone to calm down
Correct Answer: C
Rationale: During an acute panic attack, the priority intervention is to create a calm and safe environment. Teaching the client deep breathing exercises is crucial as it promotes relaxation and reduces hyperventilation, helping to manage the panic attack effectively. Encouraging the client to discuss their feelings may exacerbate the panic by increasing emotional distress. Providing a busy environment can escalate stress levels rather than alleviate them. Leaving the client alone may lead to feelings of abandonment or worsen the panic attack. Therefore, the most appropriate intervention is to teach deep breathing exercises to help the client regain control and manage the panic attack.
A healthcare professional is assessing a client with bipolar disorder who is experiencing a depressive episode. Which of the following findings should the healthcare professional expect? Select one that does not apply.
- A. High energy
- B. Feelings of hopelessness
- C. Insomnia or hypersomnia
- D. Decreased appetite
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client has been prescribed escitalopram (Lexapro) for depression. Which instruction should the nurse include in the discharge teaching?
- A. Take the medication at bedtime to prevent daytime drowsiness.
- B. Avoid consuming alcohol while taking this medication.
- C. Take the medication with food to prevent stomach upset.
- D. Discontinue the medication if you start feeling better.
Correct Answer: B
Rationale: The correct instruction for the nurse to include in the discharge teaching is to advise the client to avoid consuming alcohol while taking escitalopram (Lexapro). Alcohol can potentiate side effects such as drowsiness and dizziness when combined with this medication. Choice A is incorrect because escitalopram is usually taken in the morning due to its potential to cause insomnia if taken at bedtime. Choice C is incorrect because taking the medication with or without food does not significantly affect its absorption or side effects. Choice D is incorrect because it is essential for the client to continue taking the medication even if they start feeling better, as abruptly stopping an antidepressant can lead to withdrawal symptoms and a relapse of depression.