Question

A client with schizophrenia is seen sitting alone and talking out loud. The nurse sits down beside the client. Suddenly, the client stops and turns as if listening to someone. Which is the best response by the nurse?

Answer 1

Correct Answers:

"I don't see anyone else. What are you hearing and seeing?"

Rationale :

👁️The nurse presents reality honestly by stating that no one else is visible.

👂Asking what the client hears and sees assesses the content of the hallucination.

⚠️This assessment helps determine whether the hallucination contains commands that create a safety risk.

🤝The response acknowledges the client’s experience without confirming or arguing about the hallucination.

📌Core Message

Respond to hallucinations by presenting reality, assessing their content, and determining whether they threaten safety.

Answer 2

Correct Answers:

Allow time for the ritual while gradually implementing limits.

Rationale :

🧼Rituals temporarily reduce the severe anxiety associated with obsessive thoughts.

🌱During initial treatment, abruptly preventing the ritual can significantly increase distress and agitation.

⏳The nurse should initially allow reasonable time for the behavior while gradually establishing consistent limits.

🧠As treatment progresses, the client can learn healthier anxiety-management and coping strategies.

📌Core Message

Initial OCD care permits limited ritual performance, followed by gradual limits and development of adaptive coping skills.

Answer 3

Correct Answers:

0.8

Rationale :

⚖️The child’s weight must first be converted from pounds to kilograms by dividing by 2.2.

🧮Multiplying 34.5 kg by 0.55 mg/kg gives a prescribed dose of approximately 19 mg.

💉The available concentration is 50 mg in 2 mL, equivalent to 25 mg/mL.

🎯Dividing the required dose by the concentration gives 0.76 mL, which rounds to 0.8 mL.

📌Core Message

After converting pounds to kilograms and applying the medication concentration, the correct volume is 0.8 mL.

Answer 4

Correct Answers:

Lorazepam

Rationale :

💊Lorazepam is a benzodiazepine used to manage acute manifestations of alcohol withdrawal.

🧠It enhances inhibitory GABA activity and reduces central nervous system hyperexcitability.

🫨Diaphoresis and moderate hand tremors are characteristic early manifestations of withdrawal.

🛡️Prompt benzodiazepine treatment also helps prevent progression to seizures and delirium tremens.

📌Core Message

Lorazepam controls acute alcohol-withdrawal symptoms and reduces the risk of serious neurological complications.

Answer 5

Correct Answers

Blank 1 Correct Option: Cardiac status
Blank 2 Correct Option: Purging episodes

Rationale :

❤️The client’s weak, thready pulse of 142 beats/min and potassium level of 2.9 mEq/L indicate an immediate cardiac risk.

⚡Severe hypokalemia can disrupt cardiac conduction and cause life-threatening dysrhythmias.

📟The nurse should prioritize assessment and stabilization of the client’s cardiac status, including cardiac monitoring.

🔄After immediate safety is addressed, the recurrent purging episodes must be managed because they are causing continued electrolyte loss.

📌Core Message

Severe hypokalemia with marked tachycardia makes cardiac stabilization the priority, followed by controlling the purging behavior causing electrolyte loss.

Answer 6

Correct Answers:

"This medication will cause fever."

Rationale :

🌡️Fever is not an expected routine effect of fluoxetine and requires further clarification.

🚨Fever accompanied by agitation, confusion, sweating, tremor, or muscle rigidity may indicate serotonin syndrome.

📞The client should report these manifestations promptly because serotonin syndrome can become life-threatening.

📚Expected teaching includes possible sexual dysfunction, weight changes, and morning administration when the medication causes activation.

📌Core Message

Fever is not an expected harmless effect of fluoxetine and may signal serotonin syndrome, especially with other neurological symptoms.

Answer 7

Correct Answers:

Hold the next dose of lithium and notify the healthcare provider.

Rationale :

⚠️New nausea, tremors, and increased thirst can indicate rising lithium levels or early toxicity.

🧂Lithium has a narrow therapeutic range, so potentially toxic manifestations require prompt evaluation.

🧪The nurse should hold the medication and notify the provider so a serum lithium level and renal function can be assessed.

🚰Fluid or sodium imbalance can reduce lithium clearance and increase the risk of toxicity.

📌Core Message

Suspected lithium toxicity requires holding the medication, notifying the provider, and checking the client’s serum lithium level.

Answer 8

Correct Answers:

Histrionic personality disorder

Rationale :

🎭Histrionic personality disorder is characterized by excessive emotionality and attention-seeking behavior.

👠Flamboyant clothing and theatrical makeup may be used to attract and maintain attention.

🗣️Clients may display dramatic speech, rapidly changing emotions, and exaggerated self-expression.

🤝Nursing care should maintain clear boundaries while encouraging more effective interpersonal coping skills.

📌Core Message

Dramatic emotional expression and flamboyant appearance are characteristic of histrionic personality disorder.

Answer 9

Correct Answers:

Associative looseness

Rationale :

🔗Associative looseness involves shifting between subjects that have little or no logical connection.

🏠The client moves from houses to a ship and then to cockroaches without a clear meaningful link.

🧠This disturbance reflects disorganized thought commonly associated with schizophrenia.

📝The nurse should document the speech objectively and continue assessing the client’s thought process.

📌Core Message

Abrupt movement among unrelated but understandable ideas demonstrates associative looseness.

Answer 10

Correct Answers:

"I should set the unit's rules and expectations to prevent manipulation."

Rationale :

📏Clients with personality disorders benefit from clear, consistent rules and behavioral expectations.

🤝All staff members should enforce the same boundaries to reduce splitting and manipulation.

🗣️Expectations should be communicated calmly, directly, and without engaging in power struggles.

🛡️Consistent limit-setting promotes safety, accountability, and more adaptive interpersonal behavior.

📌Core Message

Effective personality-disorder care requires consistent rules, firm boundaries, and unified staff expectations.

1 :
A client with schizophrenia is seen sitting alone and talking out loud. The nurse sits down beside the client. Suddenly, the client stops and turns as if listening to someone. Which is the best response by the nurse?

2 :
A nurse is planning care for a newly admitted client diagnosed with obsessive-compulsive disorder who performs repetitive hand-washing rituals. Which of the following interventions is most appropriate during the initial phase of treatment?

5 :
A nurse working in an eating disorder facility is admitting a client.

Correct Answers

6 :
A nurse is teaching a client who has recently been prescribed fluoxetine for depression. Which one of the following comments by the client indicates the need for further education?

7 :
A nurse is caring for a client with bipolar disorder who has been taking lithium carbonate for the past 6 months. During the morning assessment, the client reports nausea, hand tremors, and increased thirst. Which of the following is the most appropriate action by the nurse?

8 :
A highly emotional client presents at an outpatient clinic appointment wearing flamboyant attire, spiked heels, and theatrical makeup. Which of the following personality disorders should the nurse associate with the assessment data?

9 :
The client with schizophrenia makes the following statement, "I just don't know about houses. That ship is big. Cockroaches are nasty." What term does the nurse use to document this speech pattern?

10 :
A newly-graduated nurse is working in a mental health facility. Which of the following statements made by the nurse to a co-worker indicates a good understanding of caring for a client with a personality disorder?

1 : A client with schizophrenia is seen sitting alone and talking out loud. The nurse sits down beside the client. Suddenly, the client stops and turns as if listening to someone. Which is the best response by the nurse?

2 : A nurse is planning care for a newly admitted client diagnosed with obsessive-compulsive disorder who performs repetitive hand-washing rituals. Which of the following interventions is most appropriate during the initial phase of treatment?

5 : A nurse working in an eating disorder facility is admitting a client.

Correct Answers

6 : A nurse is teaching a client who has recently been prescribed fluoxetine for depression. Which one of the following comments by the client indicates the need for further education?

7 : A nurse is caring for a client with bipolar disorder who has been taking lithium carbonate for the past 6 months. During the morning assessment, the client reports nausea, hand tremors, and increased thirst. Which of the following is the most appropriate action by the nurse?

8 : A highly emotional client presents at an outpatient clinic appointment wearing flamboyant attire, spiked heels, and theatrical makeup. Which of the following personality disorders should the nurse associate with the assessment data?

9 : The client with schizophrenia makes the following statement, "I just don't know about houses. That ship is big. Cockroaches are nasty." What term does the nurse use to document this speech pattern?

10 : A newly-graduated nurse is working in a mental health facility. Which of the following statements made by the nurse to a co-worker indicates a good understanding of caring for a client with a personality disorder?

1 :
A client with schizophrenia is seen sitting alone and talking out loud. The nurse sits down beside the client. Suddenly, the client stops and turns as if listening to someone. Which is the best response by the nurse?

2 :
A nurse is planning care for a newly admitted client diagnosed with obsessive-compulsive disorder who performs repetitive hand-washing rituals. Which of the following interventions is most appropriate during the initial phase of treatment?

5 :
A nurse working in an eating disorder facility is admitting a client.

6 :
A nurse is teaching a client who has recently been prescribed fluoxetine for depression. Which one of the following comments by the client indicates the need for further education?

7 :
A nurse is caring for a client with bipolar disorder who has been taking lithium carbonate for the past 6 months. During the morning assessment, the client reports nausea, hand tremors, and increased thirst. Which of the following is the most appropriate action by the nurse?

8 :
A highly emotional client presents at an outpatient clinic appointment wearing flamboyant attire, spiked heels, and theatrical makeup. Which of the following personality disorders should the nurse associate with the assessment data?

9 :
The client with schizophrenia makes the following statement, "I just don't know about houses. That ship is big. Cockroaches are nasty." What term does the nurse use to document this speech pattern?

10 :
A newly-graduated nurse is working in a mental health facility. Which of the following statements made by the nurse to a co-worker indicates a good understanding of caring for a client with a personality disorder?