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A nurse is planning care for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following interventions should the nurse include?
- A. Encourage the client to listen to loud music
- B. Ask the client directly about the content of the hallucinations
- C. Instruct the client to ignore the voices
- D. Avoid discussing the hallucinations with the client
Correct Answer: B
Rationale: The correct answer is B: Ask the client directly about the content of the hallucinations. This intervention is important as it helps the nurse understand the nature and content of the hallucinations, allowing for better assessment and tailored intervention. By directly asking the client, the nurse can gather valuable information to provide appropriate care and support. Encouraging the client to listen to loud music (A) may exacerbate the hallucinations. Instructing the client to ignore the voices (C) may not be effective and could lead to increased distress. Avoiding discussing the hallucinations with the client (D) hinders the therapeutic communication and understanding of the client's experience.
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A nurse is assessing a newly admitted client who has schizophrenia and takes thioridazine. Which of the following findings should the nurse document as an adverse effect of this medication?
- A. Anhedonia
- B. Waxy flexibility
- C. Contractions of the jaw
- D. Incongruent affect
Correct Answer: C
Rationale: The correct answer is C: Contractions of the jaw. Thioridazine is an antipsychotic medication known to cause extrapyramidal side effects such as dystonia, which can manifest as contractions of the jaw. Anhedonia (A) is the inability to experience pleasure, not a side effect of thioridazine. Waxy flexibility (B) is a symptom of catatonia, not a side effect of thioridazine. Incongruent affect (D) refers to a mismatch between expression and emotion, not a side effect of thioridazine.
A nurse is caring for a client who has post-traumatic stress disorder (PTSD). Which of the following interventions should the nurse include in the plan of care?
- A. Encourage the client to discuss past trauma
- B. Provide a structured routine
- C. Discourage emotional expression
- D. Limit social interactions
Correct Answer: B
Rationale: The correct answer is B: Provide a structured routine. Individuals with PTSD often benefit from a predictable routine as it provides a sense of safety and control. This intervention helps regulate emotions and reduces anxiety by creating a stable environment. Encouraging the client to discuss past trauma (A) may worsen symptoms if the client is not ready. Discouraging emotional expression (C) can be harmful as it may lead to emotional suppression. Limiting social interactions (D) may increase feelings of isolation and exacerbate symptoms. It's important to prioritize stability and structure in the plan of care for clients with PTSD.
A nurse is creating a plan of care for a client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan?
- A. Weigh the client twice per day
- B. Prepare the client for electroconvulsive therapy
- C. Set a weight gain goal of 2.2kg (5lbs) per week
- D. Encourage the client to participate in family therapy
Correct Answer: C
Rationale: The correct answer is C: Set a weight gain goal of 2.2kg (5lbs) per week. This intervention is appropriate for a client with anorexia nervosa to promote healthy weight restoration. Rapid weight gain can be harmful, so setting a realistic goal helps prevent complications. Weighing the client twice per day (A) can exacerbate anxiety and reinforce obsessive behaviors. Electroconvulsive therapy (B) is not indicated for anorexia nervosa. Encouraging family therapy (D) may be beneficial, but the priority is weight restoration.
A nurse is giving a presentation about intimate partner abuse for a community group. Which of the following statements by a group member indicates understanding of the teaching?
- A. Survivors of abuse often feel guilty
- B. Abusers often have high self-esteem
- C. The honeymoon stage of violence usually gets longer over time
- D. As abuse continues, victims become more determined to be independent
Correct Answer: A
Rationale: Correct Answer: A: Survivors of abuse often feel guilty
Rationale: This statement indicates understanding of the psychological impact of intimate partner abuse. Guilt is a common emotion experienced by survivors due to manipulation and blame from the abuser. It reflects the internalized self-blame and shame that many survivors struggle with.
Summary of other choices:
B: Abusers often have high self-esteem - Incorrect. Abusers typically have low self-esteem and use abuse as a way to exert power and control.
C: The honeymoon stage of violence usually gets longer over time - Incorrect. The honeymoon phase tends to decrease over time as abuse cycles escalate.
D: As abuse continues, victims become more determined to be independent - Incorrect. Victims often experience increased isolation and dependency on the abuser.
A nurse in a mental health facility is assessing a client who has schizophrenia. The nurse should document which of the following as a positive symptom?
- A. Social withdrawal
- B. Flat affect
- C. Delusions
- D. Lack of motivation
Correct Answer: C
Rationale: The correct answer is C: Delusions. Positive symptoms are behaviors or experiences that are added to a person's personality, such as hallucinations or delusions. Delusions are false beliefs that are not based on reality. In the context of schizophrenia, delusions are considered positive symptoms because they represent an addition to a person's usual behavior or mental state. Social withdrawal (A), flat affect (B), and lack of motivation (D) are considered negative symptoms of schizophrenia, as they involve a decrease or absence of normal behaviors or emotions. Therefore, the nurse should document delusions as a positive symptom in the assessment of the client with schizophrenia.