Nurs 311: Quiz 2 (Week 4) Questions With Complete
Solutions
A delusional pt refuses to eat because of a belief that the food is
poisoned.
What is the MOST appropriate initial nursing intervention?
Correct Answers State that the food is not poisoned.
A pt diagnosed with schizophrenia is experiencing auditory
hallucinations. A RN makes the following statements when
interacting with this pt. Correct Answers "Hearing voices must
be frightening."
"The voices you hear are part of your illness"
"I do not hear any voices."
"Come with me for a walk"
"Let's play cards with another client in the recreation room."
A pt experiencing hallucinations tell a RN, "The voices are
telling me I'm no good." The pt asks whether the RN hears the
voices.
Which is the RN's MOST appropriate response? Correct
Answers "No, I do not hear the voices, but I believe you can
hear them."
A pt in the early dementia stage of Alzheimer's disease is
admitted to a long term care facility.
Which activities must the RN initiate? Correct Answers Weigh
the pt once a week.
, Have specialized rehabilitation equipment available.
Establish a schedule with periods of rest after activities.
A pt is delusional, talking about people who are plotting to do
harm. A RN identifies that the pt is pacing more than usual and
is concerned that the pt is beginning to lose control.
What is the BESt nursing intervention? Correct Answers Move
the pt to a quiet place on the unit.
A pt tells the RN, "I am a terrible, evil person; the voices are
telling me that God needs to punish me."
What is the RN's MOST therapeutic initial response? Correct
Answers "Tell me what you are thinking about yourself.
A pt who experiences auditory hallucinations agrees to discuss
alternative coping strategies with a RN. For the next 3 days
when the RN attempts to focus on alternative strategies, the pt
gets up and leaves the interaction.
What is the RN's MOSt therapeutic response? Correct Answers
"You seem very uncomfortable every time I bring up a new way
to cope."
A pt with a history of schizophrenia attends the mental health
clinic for a regularly scheduled group therapy session. The pt
arrives agitated and exhibits behavior that indicates the hearing
of voices. When a RN begins to walk toward the pt, the pt pulls
out a large knife.
Solutions
A delusional pt refuses to eat because of a belief that the food is
poisoned.
What is the MOST appropriate initial nursing intervention?
Correct Answers State that the food is not poisoned.
A pt diagnosed with schizophrenia is experiencing auditory
hallucinations. A RN makes the following statements when
interacting with this pt. Correct Answers "Hearing voices must
be frightening."
"The voices you hear are part of your illness"
"I do not hear any voices."
"Come with me for a walk"
"Let's play cards with another client in the recreation room."
A pt experiencing hallucinations tell a RN, "The voices are
telling me I'm no good." The pt asks whether the RN hears the
voices.
Which is the RN's MOST appropriate response? Correct
Answers "No, I do not hear the voices, but I believe you can
hear them."
A pt in the early dementia stage of Alzheimer's disease is
admitted to a long term care facility.
Which activities must the RN initiate? Correct Answers Weigh
the pt once a week.
, Have specialized rehabilitation equipment available.
Establish a schedule with periods of rest after activities.
A pt is delusional, talking about people who are plotting to do
harm. A RN identifies that the pt is pacing more than usual and
is concerned that the pt is beginning to lose control.
What is the BESt nursing intervention? Correct Answers Move
the pt to a quiet place on the unit.
A pt tells the RN, "I am a terrible, evil person; the voices are
telling me that God needs to punish me."
What is the RN's MOST therapeutic initial response? Correct
Answers "Tell me what you are thinking about yourself.
A pt who experiences auditory hallucinations agrees to discuss
alternative coping strategies with a RN. For the next 3 days
when the RN attempts to focus on alternative strategies, the pt
gets up and leaves the interaction.
What is the RN's MOSt therapeutic response? Correct Answers
"You seem very uncomfortable every time I bring up a new way
to cope."
A pt with a history of schizophrenia attends the mental health
clinic for a regularly scheduled group therapy session. The pt
arrives agitated and exhibits behavior that indicates the hearing
of voices. When a RN begins to walk toward the pt, the pt pulls
out a large knife.
