A delusional client has refused to eat for the past 24 hours because, he says, "the food is
poisoned." How should the nurse respond?
1
"Why do you think that the food is poisoned?"
Correct2
"You feel worried that someone wants to poison you?"
3
"This feeling is a symptom of your illness. It's not real."
4
"You'll be safe with me. I won't let anyone poison you."
It is important to help the client focus on feelings, and "You feel worried that someone wants to
poison you?" is the only response that helps achieve this goal. Why questions call for a
conclusion rather than an exploration of the issue; the client may not have the answer. Although
stating that the feeling is a symptom of the client's illness is true, it is not something that the
client is ready to understand; also, it is a closed statement. "You'll be safe with me. I won't let
anyone poison you" is false reassurance and is not realistic; the client still is concerned about
what will happen when the nurse is not there.
60%of students nationwide answered this question correctly.
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22.
A client on the psychiatric unit tells the nurse, "The voices have told me that I'm in danger. They
say I'll be safe only if I stay in this room, wear these clothes, and avoid stepping on the cracks
between the floor tiles." What is the best initial response by the nurse?
1
"Don't worry. You're safe here. Are you afraid that I'll let someone hurt you?"
Correct2
"I know that these voices are real to you, but I want you to know that I don't hear them."
3
"Tell me more about the voices. Are they male or female? How many voices do you hear?"
4
"You need to leave this room and get your mind occupied so the voices don't bother you
anymore."
"I know that these voices are real to you, but I want you to know that I don't hear them"
demonstrates recognition and acceptance of the client's feelings and also points out reality.
"Don't worry. You're safe here. Are you afraid that I will let someone hurt you?" provides false
reassurance; the client has no reason to trust that the nurse can provide protection. Focusing on
the content of the delusion will reinforce the delusion. Encouraging the client to focus on
hallucinations tends to strengthen and confirm them. "You need to leave this room and get your
mind occupied so the voices don't bother you anymore" denies the client's feelings and may
increase anxiety.
61%of students nationwide answered this question correctly.
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23.
A couple arrives at the mental health clinic for counseling because the husband consistently
believes that his wife is having multiple affairs. After several sessions a delusional disorder is
diagnosed. What specific subtype of the delusion does the nurse identify?
Correct1
Jealousy
2
Somatic
3
Grandiose
4
Persecutory
A client who is convinced that a mate is unfaithful exhibits delusional jealousy. Somatic
delusions concern preoccupation with the body, including complaints of disfigurement,
nonfunctioning body parts, insect infestation, and presence of a serious illness. In a grandiose
delusion, the client seeks a position of power by expressing an exaggerated belief in his or her
importance or identity. Clients with persecutory delusions believe that they are being conspired
against, spied on, drugged, or poisoned.
55%of students nationwide answered this question correctly.
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24.
A nurse is managing the care of a client with recently diagnosed schizophrenia. Effective
therapeutic communication will directly affect which client-focused outcomes? Select all that
apply.
1
The client will become capable of part-time employment.
Correct 2
The client will effectively express emotional and physical needs.
3
The client will demonstrate wellness reflective of physical potential.
Correct 4
The client will demonstrate an understanding of the mental health disorder.
Correct 5
The client will recognize the issues most important to managing this disorder.
Therapeutic communication facilitates the exchange of information between the nurse and the
client that focuses on the client's attaining health and wellness. This information can be directed
towards the client's health needs such as the effective expression of the client's physical and
emotional needs, the understanding of the cause and prognosis of the current mental health
,problem, and the recognition of issues important to the management of the client's health issues.
The client's ability to maintain part-time employment and the client's physical health potential
are minimally affected by therapeutic communication.
48%of students nationwide answered this question correctly.
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25.
A client exhibiting manic behavior is admitted to the psychiatric hospital. Which room
assignment is the most appropriate for this client?
1
With a client who is very quiet
Correct2
Alone in a sparsely furnished room
3
Alone in a room at the end of the hall
4
With a client exhibiting similar behavior
Overactive individuals are stimulated by environmental factors; one responsibility of the nurse is
to simplify their surroundings as much as possible. The quiet client may become the target of this
client's overactivity. The client should be placed in a room near the nursing staff to prevent harm
to self and others. Two overactive clients together will produce excessive stimuli for each other.
69%of students nationwide answered this question correctly.
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26.
A client with the diagnosis of schizophrenia who has been hospitalized on a mental health unit
for 2 weeks is to be discharged home. The client is vacillating between being happy and sad
about going home. What term best describes these conflicting emotions?
1
Double bind
Correct2
Ambivalence
3
Loose association
4
Inappropriate affect
The simultaneous existence of two conflicting emotions, impulses, or desires is known as
ambivalence. A single communication containing two conflicting messages is known as a
double-bind message. A lack of connections between thoughts is known as loose associations.
, Inappropriate affect is not two conflicting emotions but instead the inappropriate expression of
emotions.
57%of students nationwide answered this question correctly.
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27.
Olanzapine (Zyprexa) is prescribed for a client with bipolar disorder, manic episode. What
cautionary advice should the nurse give the client?
Correct1
Sit up slowly.
2
Report double vision.
3
Expect increased salivation.
4
Take the medication on an empty stomach.
Olanzapine (Zyprexa), a thienobenzodiazepine, can cause orthostatic hypotension. Blurred, not
double, vision may occur. Decreased salivation is an effect of olanzapine. It may also cause
nausea and other gastrointestinal upsets and should be taken with fluid or food.
62%of students nationwide answered this question correctly.
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28.
A client who has been admitted with a diagnosis of schizophrenia says to the nurse, "Yes, it's
March. March is Little Women. That's literal, you know." These statements illustrate:
1
Echolalia
2
Neologisms
3
Flight of ideas
Correct4
Loosening of associations
Loose associations are thoughts that are presented without the logical connections that are
usually necessary for the listener to interpret the message. Echolalia is the purposeless repetition
of words spoken by others or repetition of overheard sounds. Neologisms are new meaningless
words coined by the client or new, unique meanings given to old words. Flight of ideas is the
rapid skipping from one thought to another; these thoughts usually have only superficial or
chance relationships.
54%of students nationwide answered this question correctly.
poisoned." How should the nurse respond?
1
"Why do you think that the food is poisoned?"
Correct2
"You feel worried that someone wants to poison you?"
3
"This feeling is a symptom of your illness. It's not real."
4
"You'll be safe with me. I won't let anyone poison you."
It is important to help the client focus on feelings, and "You feel worried that someone wants to
poison you?" is the only response that helps achieve this goal. Why questions call for a
conclusion rather than an exploration of the issue; the client may not have the answer. Although
stating that the feeling is a symptom of the client's illness is true, it is not something that the
client is ready to understand; also, it is a closed statement. "You'll be safe with me. I won't let
anyone poison you" is false reassurance and is not realistic; the client still is concerned about
what will happen when the nurse is not there.
60%of students nationwide answered this question correctly.
View Topics
11156362
Confidence: Skipped
Stats
Issue with this question?
22.
A client on the psychiatric unit tells the nurse, "The voices have told me that I'm in danger. They
say I'll be safe only if I stay in this room, wear these clothes, and avoid stepping on the cracks
between the floor tiles." What is the best initial response by the nurse?
1
"Don't worry. You're safe here. Are you afraid that I'll let someone hurt you?"
Correct2
"I know that these voices are real to you, but I want you to know that I don't hear them."
3
"Tell me more about the voices. Are they male or female? How many voices do you hear?"
4
"You need to leave this room and get your mind occupied so the voices don't bother you
anymore."
"I know that these voices are real to you, but I want you to know that I don't hear them"
demonstrates recognition and acceptance of the client's feelings and also points out reality.
"Don't worry. You're safe here. Are you afraid that I will let someone hurt you?" provides false
reassurance; the client has no reason to trust that the nurse can provide protection. Focusing on
the content of the delusion will reinforce the delusion. Encouraging the client to focus on
hallucinations tends to strengthen and confirm them. "You need to leave this room and get your
mind occupied so the voices don't bother you anymore" denies the client's feelings and may
increase anxiety.
61%of students nationwide answered this question correctly.
View Topics
,11109049
Confidence: Skipped
Stats
Issue with this question?
23.
A couple arrives at the mental health clinic for counseling because the husband consistently
believes that his wife is having multiple affairs. After several sessions a delusional disorder is
diagnosed. What specific subtype of the delusion does the nurse identify?
Correct1
Jealousy
2
Somatic
3
Grandiose
4
Persecutory
A client who is convinced that a mate is unfaithful exhibits delusional jealousy. Somatic
delusions concern preoccupation with the body, including complaints of disfigurement,
nonfunctioning body parts, insect infestation, and presence of a serious illness. In a grandiose
delusion, the client seeks a position of power by expressing an exaggerated belief in his or her
importance or identity. Clients with persecutory delusions believe that they are being conspired
against, spied on, drugged, or poisoned.
55%of students nationwide answered this question correctly.
View Topics
11135698
Confidence: Skipped
Stats
Issue with this question?
24.
A nurse is managing the care of a client with recently diagnosed schizophrenia. Effective
therapeutic communication will directly affect which client-focused outcomes? Select all that
apply.
1
The client will become capable of part-time employment.
Correct 2
The client will effectively express emotional and physical needs.
3
The client will demonstrate wellness reflective of physical potential.
Correct 4
The client will demonstrate an understanding of the mental health disorder.
Correct 5
The client will recognize the issues most important to managing this disorder.
Therapeutic communication facilitates the exchange of information between the nurse and the
client that focuses on the client's attaining health and wellness. This information can be directed
towards the client's health needs such as the effective expression of the client's physical and
emotional needs, the understanding of the cause and prognosis of the current mental health
,problem, and the recognition of issues important to the management of the client's health issues.
The client's ability to maintain part-time employment and the client's physical health potential
are minimally affected by therapeutic communication.
48%of students nationwide answered this question correctly.
View Topics
11110604
Confidence: Skipped
Stats
Issue with this question?
25.
A client exhibiting manic behavior is admitted to the psychiatric hospital. Which room
assignment is the most appropriate for this client?
1
With a client who is very quiet
Correct2
Alone in a sparsely furnished room
3
Alone in a room at the end of the hall
4
With a client exhibiting similar behavior
Overactive individuals are stimulated by environmental factors; one responsibility of the nurse is
to simplify their surroundings as much as possible. The quiet client may become the target of this
client's overactivity. The client should be placed in a room near the nursing staff to prevent harm
to self and others. Two overactive clients together will produce excessive stimuli for each other.
69%of students nationwide answered this question correctly.
View Topics
11134318
Confidence: Skipped
Stats
Issue with this question?
26.
A client with the diagnosis of schizophrenia who has been hospitalized on a mental health unit
for 2 weeks is to be discharged home. The client is vacillating between being happy and sad
about going home. What term best describes these conflicting emotions?
1
Double bind
Correct2
Ambivalence
3
Loose association
4
Inappropriate affect
The simultaneous existence of two conflicting emotions, impulses, or desires is known as
ambivalence. A single communication containing two conflicting messages is known as a
double-bind message. A lack of connections between thoughts is known as loose associations.
, Inappropriate affect is not two conflicting emotions but instead the inappropriate expression of
emotions.
57%of students nationwide answered this question correctly.
View Topics
11140892
Confidence: Skipped
Stats
Issue with this question?
27.
Olanzapine (Zyprexa) is prescribed for a client with bipolar disorder, manic episode. What
cautionary advice should the nurse give the client?
Correct1
Sit up slowly.
2
Report double vision.
3
Expect increased salivation.
4
Take the medication on an empty stomach.
Olanzapine (Zyprexa), a thienobenzodiazepine, can cause orthostatic hypotension. Blurred, not
double, vision may occur. Decreased salivation is an effect of olanzapine. It may also cause
nausea and other gastrointestinal upsets and should be taken with fluid or food.
62%of students nationwide answered this question correctly.
View Topics
11138669
Confidence: Skipped
Stats
Issue with this question?
28.
A client who has been admitted with a diagnosis of schizophrenia says to the nurse, "Yes, it's
March. March is Little Women. That's literal, you know." These statements illustrate:
1
Echolalia
2
Neologisms
3
Flight of ideas
Correct4
Loosening of associations
Loose associations are thoughts that are presented without the logical connections that are
usually necessary for the listener to interpret the message. Echolalia is the purposeless repetition
of words spoken by others or repetition of overheard sounds. Neologisms are new meaningless
words coined by the client or new, unique meanings given to old words. Flight of ideas is the
rapid skipping from one thought to another; these thoughts usually have only superficial or
chance relationships.
54%of students nationwide answered this question correctly.
