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A client with schizophrenia is experiencing auditory hallucinations. Which nursing intervention should the nurse implement to address this symptom?
- A. Encourage the client to express feelings about the hallucinations.
- B. Distract the client from the hallucinations.
- C. Provide reality-based feedback about the hallucinations.
- D. Encourage the client to ignore the hallucinations.
Correct Answer: C
Rationale: The correct intervention for a client experiencing auditory hallucinations in schizophrenia is to provide reality-based feedback about the hallucinations. By providing reality-based feedback, the nurse helps the client differentiate between what is real and what is not, which can help decrease the distress and impact of the hallucinations on the client's perception of reality. Encouraging the client to express feelings (Choice A) may not directly address the hallucinations. Distracting the client (Choice B) may temporarily alleviate the symptoms but does not help the client differentiate reality from hallucinations. Encouraging the client to ignore the hallucinations (Choice D) may not be effective as the client may struggle to do so without appropriate guidance.
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After fasting from 10 p.m. the previous evening, a client finds out that the blood test has been canceled. The client swears at the nurse and states, 'You are incompetent!' Which is the nurse's best response?
- A. Do you believe that I was the cause of your blood test being canceled?
- B. I see that you are upset, but I feel uncomfortable when you swear at me.
- C. Have you ever thought about ways to express anger appropriately?
- D. I'll give you some space. Let me know if you need anything.
Correct Answer: B
Rationale: In this scenario, the most appropriate response for the nurse is option B. By acknowledging the client's feelings and setting a boundary regarding inappropriate behavior, the nurse addresses the situation with empathy. This response demonstrates understanding of the client's emotions while also maintaining a professional standard by expressing discomfort with swearing. Option A could come off as defensive and may escalate the situation. Option C may be perceived as condescending and not immediately address the client's behavior. Option D, although offering space, does not directly address the inappropriate behavior and misses an opportunity to set a professional boundary.
When assessing a client's behavior for potential aggression, what behavior would be recognized as the highest predictor of future violence?
- A. Pacing and restlessness
- B. Verbal threats
- C. History of violence
- D. Substance abuse
Correct Answer: C
Rationale: A history of violence is considered the highest predictor of future violence. Clients who have a history of violent behavior are more likely to engage in violent acts in the future compared to those who exhibit other behaviors such as pacing, making verbal threats, or having substance abuse issues. Understanding a client's history of violence is crucial in assessing the risk of potential aggression and violence. Pacing and restlessness, verbal threats, and substance abuse can be concerning behaviors but do not carry the same predictive value for future violence as a documented history of violent behavior.
During a community education session on mental health, which statement about stigma and mental illness is correct?
- A. Stigma has no impact on treatment outcomes.
- B. Stigma can prevent individuals from seeking treatment.
- C. Stigma is only a problem in developing countries.
- D. Stigma related to mental illness is decreasing significantly worldwide.
Correct Answer: B
Rationale: The correct answer is B: 'Stigma can prevent individuals from seeking treatment.' Stigma surrounding mental illness can create barriers for individuals seeking treatment. It can lead to feelings of shame, fear of judgment, and discrimination, which may deter individuals from accessing the necessary support and care they need. Choices A, C, and D are incorrect. Stigma does have a significant impact on treatment outcomes by discouraging individuals from seeking help, it is not limited to developing countries but is a global issue, and unfortunately, stigma related to mental illness is still prevalent worldwide, although efforts are being made to reduce it.
A client with bipolar disorder is experiencing a depressive episode. Which intervention should the nurse implement to support the client's recovery?
- A. Encourage the client to engage in physical activity.
- B. Encourage the client to maintain a regular sleep schedule.
- C. Encourage the client to set realistic goals for daily activities.
- D. Encourage the client to express feelings of sadness.
Correct Answer: C
Rationale: During a depressive episode in bipolar disorder, encouraging the client to set realistic goals for daily activities can be beneficial. Setting achievable goals can provide structure, a sense of accomplishment, and help in breaking tasks into manageable steps, which can support the client's recovery process. Options A and B, while important in managing bipolar disorder, may not directly address the client's depressive symptoms during this episode. Option D, encouraging the client to express feelings of sadness, is not as effective as setting achievable goals in providing structure and a sense of accomplishment during a depressive episode.
A client with schizophrenia is prescribed risperidone. Which statement by the client indicates a need for further teaching?
- A. I can stop taking this medication once I feel better.
- B. I need to avoid drinking alcohol while taking this medication.
- C. I should take this medication with food to avoid stomach upset.
- D. This medication may cause weight gain.
Correct Answer: A
Rationale: The correct answer is A. Risperidone should be taken consistently as prescribed and should not be stopped abruptly. It is essential to educate the client that discontinuing the medication without medical advice can lead to a worsening of symptoms or potential relapse. Choices B, C, and D demonstrate understanding of important considerations when taking risperidone, such as avoiding alcohol, taking it with food to reduce stomach upset, and being aware of the potential side effect of weight gain. Choice A suggests a misconception that the medication can be discontinued once the client feels better, which is incorrect and requires further clarification to ensure treatment adherence and effectiveness.