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The nurse documents that a client with schizophrenia is delusional. Which statement by the client confirms this assessment?
- A. The snakes on the wall are going to eat me
- B. The nurse at night is trying to poison me with pills
- C. The voices are telling me to kill the next person I see
- D. The fire is burning my skin away right now
- E. None
- F. None
Correct Answer: B
Rationale: The nurse at night is trying to poison me with pills' confirms a delusion, specifically a paranoid delusion, as it reflects a fixed, false belief not based in reality. The other options describe hallucinations: visual ('snakes'), auditory ('voices'), and tactile ('fire'). Delusions involve false beliefs, while hallucinations involve false sensory perceptions.
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A client requests permission for the spouse to remain in the room during the admission assessment. While interviewing the client, the nurse notes a discrepancy between the client's verbal and nonverbal communication. Which action should the nurse take?
- A. Ignore the nonverbal behavior and focus on the client's verbal messages
- B. Integrate the verbal and nonverbal messages and interpret them as one
- C. Ask the client's spouse to interpret the discrepancy
- D. Pay close attention and document the nonverbal messages
Correct Answer: D
Rationale: Paying close attention and documenting nonverbal messages gathers comprehensive data for further exploration. Ignoring nonverbal cues misses important information. Integrating messages prematurely may misinterpret the discrepancy. Asking the spouse to interpret is inappropriate and may not be accurate.
The nurse is performing the admission assessment for a client with schizophrenia in an acute care inpatient facility. The nurse should identify which observed behavior is characteristic of schizophrenia?
- A. Responds with illogical answers to questions
- B. Admits to frequently thinking about committing suicide
- C. Describes times of depression followed by feelings of euphoria
- D. Exhibits compulsive, ritualistic behaviors
Correct Answer: A
Rationale: Responding with illogical answers indicates disorganized thinking, a hallmark of schizophrenia during psychosis. Suicide thoughts are not specific to schizophrenia. Depression and euphoria suggest bipolar disorder. Compulsive behaviors are more typical of OCD.
Nurses' Notes
• Diagnosis: depression and post-traumatic stress disorder Diphenhydramine 12.5 mg PO every night at sleep (HS) • Buspirone hydrochloride 7.5 mg PO twice a day
During the conversation with the client, the nurse documents a statement by the client about wishing she had died in the crash.
During the conversation with the client, the nurse documents a statement by the client about wishing she had died in the crash. The statement by the client represents and should be followed up with an
- A. suicidal ideation, assessment of risk factors for suicide
Correct Answer: A
Rationale: The client's statement reflects suicidal ideation, requiring immediate assessment of suicide risk factors (e.g., history, stressors, support systems) to determine appropriate interventions, ranging from monitoring to psychiatric evaluation.
The nurse develops a plan of care for a female client who scratches her wrists in attempts to deal with anxiety. Which client outcome is most important to include in the plan of care?
- A. Participates in individual and group therapy
- B. Demonstrates effective ways to cope with anxiety
- C. Learns methods of relaxation to reduce anxiety
- D. Takes all antianxiety medications as prescribed
Correct Answer: B
Rationale: This outcome directly addresses the client's maladaptive coping mechanism (scratching wrists) by aiming to replace it with healthier strategies. Therapy participation and relaxation methods are important but secondary to effective coping. Medication adherence does not teach alternative coping strategies.
Mark which behaviors might be related to alcohol intoxication, acute phase of rape-trauma syndrome, or both. Tick only 1 box.
- A. Numbness: Rape-trauma syndrome
- B. Poor decision making: Alcohol intoxication
- C. Crying: Both
- D. Disbelief: Rape-trauma syndrome
- E. Irritability: Alcohol intoxication
- F. Difficulty concentrating: Both
Correct Answer: C
Rationale: Crying occurs in both alcohol intoxication (due to disinhibition) and rape-trauma syndrome (due to emotional distress). Numbness and disbelief are specific to rape-trauma syndrome. Poor decision making, irritability, and difficulty concentrating are typical of alcohol intoxication, though the latter can also occur in rape-trauma syndrome.