Nokea
Which of the following actions would NOT be helpful when dealing with Paranoid Hallucinations?
- A. Help the client relate with real persons
- B. Avoid giving attention to the content of hallucination or delusion after an initial investigation
- C. Acknowledge the clients belief in the perception but also indicate that is not shared by others
- D. Listen carefully to the content of hallucinations and delusion and encourage the client to describe them.
Correct Answer: D
Rationale: Even if you don't agree that they are under threat or at risk, try to understand how they are feeling. It's important to recognise that their feelings are very real, even if you feel the beliefs they are based on are unfounded. Focus on the level of distress they are feeling and offer comfort. It's possible to recognise their alarm and acknowledge their feelings without agreeing with the reason they feel that way.
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An 11-year-old child diagnosed with conduct disorder is admitted to the psychiatric unit for treatment. Which of the following behaviors would the nurse assess?
- A. Restlessness, short attention span, hyperactivity
- B. Physical aggressiveness, low stress tolerance disregard for the rights of others
- C. Deterioration in social functioning, excessive anxiety and worry, bizarre behavior
- D. Sadness, poor appetite and sleeplessness, loss of interest in activities
Correct Answer: B
Rationale: Physical aggressiveness, low stress tolerance, and a disregard for the rights of others are common behaviors in clients with conduct disorders. Restlessness, short attention span, and hyperactivity are typical behaviors in a client with attention deficit hyperactivity disorder. Deterioration in social functioning, excessive anxiety and worry and bizarre behaviors are typical in schizophrenic disorders. Sadness, poor appetite, sleeplessness, and loss of interest in activities are behaviors commonly seen in depressive disorders.
The nurse explains to a mental health care technician that a client's obsessive-compulsive behaviors are related to unconscious conflict between id impulses and the superego (or conscience). On which of the following theories does the nurse base this statement?
- A. Behavioral theory
- B. Cognitive theory
- C. Interpersonal theory
- D. Psychoanalytic theory
Correct Answer: D
Rationale: Psychoanalytic is based on Freud's beliefs regarding the importance of unconscious motivation for behavior and the role of the id and superego in opposition to each other. Behavioral cognitive and interpersonal theories do not emphasize unconscious conflicts as the basis for symptomatic behavior.
While the nurse was taking her blood pressure, the patient suddenly stated. 'They are talking about me!' She was referring to other patients who were waiting for their consultation. Which of the following should be the APPROPRIATE nursing action?
- A. Present the reality situation
- B. Distract patient's attention
- C. Disagree with the patient
- D. Validate the statement
Correct Answer: A
Rationale: The client is presenting false beliefs or delusions. Intervention would include focusing on and directing the client's attention to concrete things in the environment as a way to present reality.
Prior to administering chlorpromazine (Thorazine) to an agitated client, the nurse should:
- A. Assess skin color and sclera
- B. Assess the radial pulse
- C. Take the client's blood pressure
- D. Ask the client to void
Correct Answer: C
Rationale: Because chlorpromazine (Thorazine) can cause a significant hypotensive effect (and possible client injury), the nurse must assess the client's blood pressure (lying, sitting, and standing) before administering this drug. If the client had taken the drug previously, the nurse would also need to assess the skin color and sclera for signs of jaundice, a possible drug side affect; however, based on the information given here, there is no evidence that the client has received chlorpromazine before. Although the drug can cause urine retention, asking the client to avoid will not alter this anticholinergic effect.
An outpatient mental health clinic-based adult psychiatric and mental health nurse practitioner treats a 32-year-old patient who has diabetes and a major depressive disorder. The patient reports an improved and stable mood on a trial of duloxetine (Cymbalta), but experiences continued neuropathic pain. The nurse practitioner's initial intervention is to:
- A. add gabapentin (Neurontin) to the treatment regimen.
- B. conduct additional diagnostic tests.
- C. contact the patient's endocrinologist.
- D. increase the dosage of duloxetine (Cymbalta).
Correct Answer: A
Rationale: Gabapentin is effective for neuropathic pain and complements duloxetine's antidepressant effect, making it a practical initial step. Tests or consultation may follow if needed, and increasing duloxetine risks side effects without guaranteed pain relief.