Nokea
Which of the following are common symptoms of schizophrenia? Select one that does not apply.
- A. Delusions
- B. Hallucinations
- C. Organized speech
- D. Catatonia
Correct Answer: C
Rationale: Common symptoms of schizophrenia include delusions, hallucinations, disorganized speech, and catatonia. Organized speech is not a typical symptom of schizophrenia. In schizophrenia, individuals often exhibit disorganized or incoherent speech patterns, rather than organized speech. Euphoria is not typically associated with schizophrenia, making it an incorrect choice.
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A client diagnosed with bipolar disorder is experiencing a manic episode. Which of the following actions should the nurse take first?
- A. Encourage the client to participate in group therapy.
- B. Place the client in a private room to decrease stimulation.
- C. Encourage the client to participate in physical activity.
- D. Administer a prescribed sedative.
Correct Answer: B
Rationale: During a manic episode, individuals with bipolar disorder may be easily overstimulated. Placing the client in a private room to decrease environmental stimuli is the priority intervention. This action can help reduce the risk of exacerbating manic symptoms and promote a calmer environment for the client. Choice A is not the priority as group therapy may be overwhelming during a manic episode. Choice C could potentially increase stimulation rather than decrease it. Choice D should not be the first action as sedatives are generally not the initial intervention for managing manic episodes.
When assessing a client diagnosed with major depressive disorder who states, 'I feel like I can't go on,' which of the following actions should the nurse take first?
- A. Administer a prescribed antidepressant medication.
- B. Ask the client if they have a plan to commit suicide.
- C. Encourage the client to attend a support group.
- D. Contact the client's family to provide support.
Correct Answer: B
Rationale: The priority action for the nurse is to assess the client's risk for suicide. By asking if the client has a plan to commit suicide, the nurse can determine the immediate safety of the client and take appropriate interventions to prevent harm. Administering antidepressant medication is not the first action to take in this situation as assessing the client's safety is the priority. Encouraging the client to attend a support group or contacting the client's family, although beneficial, are not immediate actions to ensure the client's safety in a crisis situation.
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.
When planning care for a client with schizophrenia, which of the following interventions should be included in the plan of care?
- A. Encourage reality testing
- B. Provide opportunities for socialization
- C. Monitor for command hallucinations
- D. Promote adherence to medication regimen
Correct Answer: A
Rationale: When caring for a client with schizophrenia, encouraging reality testing is essential. This intervention assists the client in distinguishing between delusions and reality, aiding in their treatment. While providing opportunities for socialization can help reduce isolation, monitoring for command hallucinations is crucial for the client's safety. Promoting adherence to the medication regimen is vital for symptom management. Addressing delusional thoughts in a therapeutic manner is preferable to outright discouragement, fostering a supportive environment for the client.
A teenage boy is attracted to a female teacher. Without objective evidence, a school nurse overhears the boy state, 'I know she wants me.' This statement reflects which defense mechanism?
- A. Displacement
- B. Projection
- C. Rationalization
- D. Sublimation
Correct Answer: B
Rationale: The correct answer is B: Projection. The nurse should determine that the client's statement reflects the defense mechanism of projection. Projection involves attributing one's unacceptable feelings or impulses to another person. By projecting these feelings onto someone else, the individual reduces their own anxiety. Displacement involves transferring feelings from one target to another, not attributing them to another person. Rationalization involves making excuses to justify behavior, not attributing feelings to others. Sublimation involves channeling unacceptable drives or impulses into more constructive and acceptable activities, not attributing feelings to another person.