Correct Answer!!
The nurse is conducting discharge teaching for a client with schizophrenia who plans to live in a
group home. Which statement is most indicative of the need for careful follow-up after
discharge?
a. Crickets are a good source of protein.
b. I have not heard any voices for a week.
c. Only my belief in God can help me.
d. Sometimes I have a hard time sitting still - CORRECT ANSWER ✔✔- *C. Only my belief in
God can help me.*
The most frequent cause of increased symptoms in psychotic clients is non-compliance with the
medication regimen. If clients believe that "God alone" is going to heal them (C) then they may
discontinue their medication, so (C) would pose the greatest threat to this client's prognosis. (A)
would require further teaching, but is not as significant a statement as (C). (B) indicates an
improvement in the client's condition. (D) may be a sign of anxiety that could improve with tx,
but does not have the priority of (C).
A child is brought to the ER with a broken arm. Because of other injuries, the nurse suspects the
child may be a victim of abuse. When the nurse tries to give the child an injection, the child's
mother becomes very loud and shouts, "I won't leave my son! Don't you touch him! You'll hurt
my child!" What is the best interpretation of the mother's statements? The mother is
a. regressing to an earlier behavior pattern.
b. sublimating her anger.
c. projecting her feelings onto the nurse.
d. suppressing her fear. - CORRECT ANSWER ✔✔- *C. projecting her feelings onto the nurse.*
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,Projection is attributing one's own thoughts, impulses, or behaviors onto another--it is the mother
who is probably harming the child and she is attributing her actions to the nurse (C). The mother
may be immature, but (A) is not the best description of her behavior. (B) is substituting a socially
acceptable feeling for an unacceptable one. These are not socially acceptable feelings. The
mother may be suppressing her fear (D) by displaying anger, but such an interpretation cannot be
concluded from the data presented.
An elderly female client with advanced dementia is admitted to the hospital with a fractured hip.
The client repeatedly tells the staff, "Take me home. I want my Mommy." Which response is
best for the nurse to provide?
a. Orient the client to the time, place, and person.
b. Tell the client that the nurse is there and will help her.
c. Remind the client that her mother is no longer living.
d. Explain the seriousness of her injury and need for hospitalization. - CORRECT ANSWER
✔✔- *B. Tell the client that the nurse is there and will help her.*
Those with dementia often refer to home or parents when seeking security and comfort. The
nurse should use the techniques of "offering self" and "talking to the feelings" to provide
reassurance (B). Clients with advanced dementia have permanent physiological changes in the
brain (plaques and tangles) that prevent them from comprehending and retaining new
information, so (A, C, and D) are likely to be of little use to this client and do not help the clients
emotional needs.
A 27 y/o F client is admitted to the psychiatric hospital with a dx of bipolar disorder, manic
phase. She is demanding and active. Which intervention should the nurse include in this client's
plan of care?
a. Schedule her to attend various group activities.
b. Reinforce her ability to make her own decisions.
c. Encourage her to identify feelings of anger.
d. Provide a structured environment with little stimuli. - CORRECT ANSWER ✔✔- *D. Provide
a structured environment with little stimuli.*
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,Clients in the manic phase of bipolar disorder require decreased stimuli and a structured
environment (D). Plan noncompetitive activities that can be carried out alone. (A) is
contraindicated; stimuli should be reduced as much as possible. Impulsive decision-making is
characteristic of clients with bipolar disorder. To prevent future complications, the nurse should
monitor these clients' decisions and assist them in decision-making process (B). (C) is more often
associated with depression than with bipolar disorder.
An adult male client who was admitted to the mental hospital unit yesterday tells the nurse that
microchips were planted in his head for military surveillance of his every move. Which response
is best for the nurse to provide?
a. You are in the hospital, and I am the nurse caring for you.
b. It must be difficult for you to control your anxious feelings.
c. Go to occupational therapy and start a project.
d. You are not in a war area now; this is the United States. - CORRECT ANSWER ✔✔- * C. Go
to occupational therapy and start a project.*
Delusions often generate fear and isolation, so the nurse should help the client participate in
activities that avoid focusing on the false belief and encourage interaction with others (C).
Delusions are often well-fixed, and though (A) reinforces reality, it is argumentative and
dismisses the clients fears. It is often difficult for the client to recognize the relationship between
delusions and anxiety (B), and the nurse should reassure the client that he is in a safe place.
Dismissing delusional thinking (D) is unrealistic because neurochemical imbalances that cause
positive symptoms of schizophrenia require antipsychotic drug therapy.
A 38 y/o F client is admitted with a dx of paranoid schizophrenia. When her tray is brought to
her, she refuses to eat and tells the nurse, "I know you're trying to poison me with that food."
Which response is most appropriate for the nurse to make?
a. I'll leave your tray here. I am available if you need anything else.
b. You're not being poisoned. Why do you think someone is trying to poison you?
c. No one on this unit has ever died from poisoning. You're safe here.
d. I will talk to your HCP about the possibility of changing your diet. - CORRECT ANSWER
✔✔- *A. I'll leave your tray here. I am available if you need anything else.*
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, (A) is the best choice cited. The nurse doesn't argue with the client nor demand that she eat, but
offers support by agreeing to "be there if needed", e.g., to warm the food. (B and C) are arguing
with the client's delusions, and (B) asks "why" which is usually not a good question for a
psychotic client. (D) has nothing to do with the actual problem; i.e., the problem is not the diet
(she thinks any food given to her is poisoned).
A homeless person who is in the manic phase of bipolar disorder is admitted to the mental health
unit. Which lab finding obtained on admission is most important for the nurse to report to the
HCP?
a. Decreased TSH level.
b. Elevated liver function profile.
c. Increased WBC count.
d. Decreased Hct and Hgb levels. - CORRECT ANSWER ✔✔- *A. Decreased TSH level.*
Hyperthyroidism causes an increased level of serum thyroid hormones (T3 and T4), which
inhibits the release of TSH (A), so the client's manic behavior may be related to an endocrine
disorder. (B, C, and D) are abnormal findings that are commonly found in the homeless
population because of poor sanitation, poor nutrition, and the prevalence of substance abuse
The nurse is planning discharge teaching for a male client with schizophrenia. The client insists
that he is returning to his apartment, although the HCP informed him that he will be moving to a
boarding home. What is the most important nursing dx for discharge planning?
a. Ineffective denial r/t situational anxiety.
b. Ineffective coping r/t inadequate support.
c. Social isolation r/t difficult interactions.
d. Self-care deficit r/t cognitive impairment. - CORRECT ANSWER ✔✔- *A. Ineffective denial
r/t situational anxiety.*
The best nursing dx is (A) because the client is unable to acknowledge the move to a boarding
home. (B, C, and D) are potential nursing diagnoses, but denial is most important because it is a
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