Question

A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The nurse also determines the client is homeless and is exhibiting suspiciousness. This client's plan of care should include what priority problem?

Answer 1

Correct Answers:

Disturbed sensory perception.

Rationale :

🧩The client is disoriented, confused, and exhibiting suspiciousness, all of which are classic signs of altered sensory input.

🧠This aligns with disturbed sensory perception, a priority problem in psychiatric care when a person’s ability to interpret environmental stimuli is impaired.

🧾The presence of suspiciousness and disorganization suggests that the client may be misperceiving reality, which directly impacts perception.

🔍Addressing this issue is crucial to reduce risk of harm and promote accurate engagement with the environment.

📌Core Message

Disturbed sensory perception is the priority when clients display confusion and suspiciousness indicating altered reality interpretation.

Answer 2

Correct Answers:

Escort the client from the group to reduce stimuli.

Rationale :

🌪️Severe anxiety requires decreased external stimulation, which cannot be achieved within a group therapy setting.

🔕The most effective response is to remove the client from a stimulating environment to help stabilize their condition.

💁‍♂️Coping techniques and education are more appropriate during mild-to-moderate anxiety but are ineffective when the client is overwhelmed.

🚶Escorting the client out provides immediate relief and is a therapeutic approach to manage severe anxiety safely.

📌Core Message

During severe anxiety, reducing external stimuli by removing the client from the environment is the most therapeutic action.

Answer 3

Correct Answers:

Methamphetamine.

Rationale :

💔Methamphetamine is a potent central nervous system stimulant that can lead to cardiovascular damage, including myocardial infarction.

🔥It causes a significant increase in heart rate and blood pressure, placing extreme strain on the heart.

🧬Unlike alcohol or marijuana, meth has a direct vasoconstrictive effect, which can cause coronary artery spasm and myocardial ischemia.

📈Clients with a history of meth use are at increased risk for acute cardiac events, particularly MIs.

📌Core Message

Methamphetamine use is strongly associated with myocardial infarction due to its intense cardiovascular effects.

Answer 4

Correct Answers:

Stimulation and dilated pupils.

Rationale :

⚡Cocaine is a potent stimulant that produces a surge of energy and sympathetic nervous system activation.

👁️Dilated pupils (mydriasis) are a typical physical sign due to heightened adrenergic stimulation.

🔥Other signs include increased heart rate, euphoria, and hypervigilance, which align with stimulant intoxication.

📋Hallucinations and depression may occur later but are not acute signs of recent use.

📌Core Message

Cocaine intoxication causes increased stimulation and dilated pupils due to adrenergic overdrive.

Answer 5

Correct Answers:

"The nurse at night is trying to poison me with pills."

Rationale :

🧠A delusion is a fixed, false belief that is resistant to reasoning or contrary evidence.

🧪This client demonstrates a paranoid delusion, believing that someone is trying to poison them without any logical basis.

🔍This differentiates from hallucinations, which are sensory perceptions (e.g., voices or images).

📌The belief about being poisoned by the nurse reflects an altered thought content, a hallmark of schizophrenia.

📌Core Message

Delusions involve false, fixed beliefs, such as thinking someone is trying to poison you.

Answer 6

Correct Answers:

Get the most difficult questions over with first.

Rationale :

🗣️Addressing suicidal ideation directly and early demonstrates therapeutic honesty and prioritizes safety.

🚨Suicidal thoughts are a psychiatric emergency, and delaying direct questioning could miss a chance to intervene.

🔍Clients in crisis often feel relief when asked directly because it shows concern and builds trust.

🧠Vague or soft approaches can be confusing and fail to assess risk clearly.

📌Core Message

In suspected suicide risk, ask direct questions early to quickly assess safety and begin intervention.

Answer 7

Correct Answers:

A young woman who suddenly goes blind with no indication of organic pathology.

Rationale :

👁️Conversion disorder involves the presence of neurological symptoms, such as blindness or paralysis, without a medical cause.

🧬The symptom is a manifestation of psychological stress unconsciously converted into a physical problem.

🔎The sudden blindness without organic findings strongly supports this diagnosis.

🧠The client is typically not consciously producing the symptoms, differentiating it from malingering.

📌Core Message

Conversion disorder presents with neurological symptoms like blindness without an identifiable medical cause.

Answer 8

Correct Answers:

Lorazepam 2 mg IM.

Rationale :

💉Delirium tremens (DTs) is a severe alcohol withdrawal complication characterized by agitation, tremors, hallucinations, and seizures.

💊Lorazepam, a benzodiazepine, is the gold standard for managing alcohol withdrawal symptoms and preventing seizures.

🚨Prompt use of lorazepam reduces the risk of serious complications and stabilizes the central nervous system.

🧠Other medications listed are inappropriate for managing DTs, which require sedative-hypnotic therapy.

📌Core Message

Lorazepam is the first-line treatment for delirium tremens in acute alcohol withdrawal.

Answer 9

Correct Answers:

Spend time sitting in silence with client.

Rationale :

🧘Clients with depression often exhibit psychomotor retardation, which delays verbal responses.

🧎Remaining silently present communicates acceptance and support without pressure to engage.

🔔This technique is therapeutic, validating the client’s feelings and encouraging communication at their pace.

📉Pushing for verbalization too early can increase anxiety or frustration in a severely depressed client.

📌Core Message

In severe depression, therapeutic silence builds trust and respects the client’s slowed response time.

Answer 10

Correct Answers:

Efforts to cut down, annoyance with questions, guilt, drinking as an "Eye-opener."

Rationale :

📋The CAGE questionnaire is a 4-question screening tool used to assess problematic alcohol use.

🔎Each letter stands for Cutting down, Annoyance, Guilt, and Eye-opener, which are red flags of alcohol misuse.

📊If the client endorses two or more items, it strongly suggests alcohol dependency and requires further evaluation.

🧠This tool focuses on behaviors and emotional responses related to drinking, not volume or lab values.

📌Core Message

The CAGE tool screens for alcohol dependency by evaluating behavioral signs like guilt and need for morning drinking.

1 :
A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The nurse also determines the client is homeless and is exhibiting suspiciousness. This client's plan of care should include what priority problem?

2 :
A nurse who is co-leading group therapy recognizes that a client is beginning to experience severe levels of anxiety. Which intervention is best for the nurse to implement?

3 :
The nurse is performing intake interviews at a psychiatric clinic. A client with a known history of drug abuse reports having had a heart attack four years ago. Use of which substance places the client at highest risk for myocardial infarction?

4 :
The nurse is assessing a client who reports using cocaine several times in the past week. Which observations should the nurse expect on assessment?

5 :
The nurse documents that a client with schizophrenia is delusional. Which statement by the client confirms this assessment?

6 :
Which is the best approach for the nurse to use when interviewing a client about suicidal ideations?

7 :
The charge nurse of the psychiatric unit observes clients in the day area. Which client is exhibiting symptoms of a conversion disorder?

9 :
When the nurse addresses questions to an adult client who is depressed, the client's responses are delayed. Which intervention should the nurse include in the client's plan of care?

10 :
The nurse is using the CAGE questionnaire as a screening tool for a client who is seeking help because his wife said he had a drinking problem. Which information should the nurse explore in depth with the client based on this screening tool?

1 : A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The nurse also determines the client is homeless and is exhibiting suspiciousness. This client's plan of care should include what priority problem?

2 : A nurse who is co-leading group therapy recognizes that a client is beginning to experience severe levels of anxiety. Which intervention is best for the nurse to implement?

3 : The nurse is performing intake interviews at a psychiatric clinic. A client with a known history of drug abuse reports having had a heart attack four years ago. Use of which substance places the client at highest risk for myocardial infarction?

4 : The nurse is assessing a client who reports using cocaine several times in the past week. Which observations should the nurse expect on assessment?

5 : The nurse documents that a client with schizophrenia is delusional. Which statement by the client confirms this assessment?

6 : Which is the best approach for the nurse to use when interviewing a client about suicidal ideations?

7 : The charge nurse of the psychiatric unit observes clients in the day area. Which client is exhibiting symptoms of a conversion disorder?

9 : When the nurse addresses questions to an adult client who is depressed, the client's responses are delayed. Which intervention should the nurse include in the client's plan of care?

10 : The nurse is using the CAGE questionnaire as a screening tool for a client who is seeking help because his wife said he had a drinking problem. Which information should the nurse explore in depth with the client based on this screening tool?

1 :
A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The nurse also determines the client is homeless and is exhibiting suspiciousness. This client's plan of care should include what priority problem?

2 :
A nurse who is co-leading group therapy recognizes that a client is beginning to experience severe levels of anxiety. Which intervention is best for the nurse to implement?

3 :
The nurse is performing intake interviews at a psychiatric clinic. A client with a known history of drug abuse reports having had a heart attack four years ago. Use of which substance places the client at highest risk for myocardial infarction?

4 :
The nurse is assessing a client who reports using cocaine several times in the past week. Which observations should the nurse expect on assessment?

5 :
The nurse documents that a client with schizophrenia is delusional. Which statement by the client confirms this assessment?

6 :
Which is the best approach for the nurse to use when interviewing a client about suicidal ideations?

7 :
The charge nurse of the psychiatric unit observes clients in the day area. Which client is exhibiting symptoms of a conversion disorder?

9 :
When the nurse addresses questions to an adult client who is depressed, the client's responses are delayed. Which intervention should the nurse include in the client's plan of care?

10 :
The nurse is using the CAGE questionnaire as a screening tool for a client who is seeking help because his wife said he had a drinking problem. Which information should the nurse explore in depth with the client based on this screening tool?