CLNS 101 Adaptive quiz Psychosis

Exam (elaborations) CLNS 101 Adaptive quiz Psychosis 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. View Topics 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 CLNS 101 Adaptive quiz Psychosis 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 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 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 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 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 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. View Topics Confidence: Skipped Stats Issue with this question? 29. A client with schizophrenia, paranoid type, is delusional, withdrawn, and negativistic. The nurse should plan to: Correct1 Invite the client to play a game of cards or board game. 2 Explain to the client the benefits of joining a group activity. 3 Encourage the client to become involved in group activities. 4 Mention to the client that the psychiatrist has ordered increased activity. Activities that require limited interpersonal contact are less threatening. Individuals with schizophrenia, paranoid type, usually do not respond to an authoritarian approach because they do not trust others, particularly those who act in an aggressive manner. Group activities require interaction with other people, which is threatening to individuals with paranoid feelings. 53%of students nationwide answered this question correctly. View Topics Confidence: Just a guess Stats Issue with this question? 30. During an assessment the nurse realizes that the client is experiencing a hallucination when the client says: 1 "I am going to save the world because I am God." Correct2 "My insides smell like they're going to just rot away." 3 "Unless I gamble at least once a week I feel extremely anxious." Incorrect4 "It's crazy, but I keep thinking that something terrible will happen to my baby." The response "My insides smell like they're going to just rot away" is an example of an olfactory hallucination, a sense of perception for which no external stimulus exists. The response "I am going to save the world because I am God" is an example of a delusion of grandeur. A delusion is a fixed false belief held to be true by the person even in the presence of evidence to the contrary. The response "Unless I gamble at least once a week I feel extremely anxious" is an example of a compulsion. A compulsion is a repetitive, intrusive urge to perform an act contrary to one's ordinary wishes or standards. The response "It's crazy, but I keep thinking that something terrible will happen to my baby" is an example of an obsession. An obsession is an insistent, painful, intrusive idea, impulse, or emotion that arises from within and cannot be suppressed or ignored. A client paces back and forth across the floor, speaks incoherently, and continually talks to and verbally fights with people who are not present. What is the nurse's initial therapeutic intervention? 1 Setting limits on the client's verbal aggression 2 Isolating the client to decrease the aggressive behavior 3 Establishing a relationship to reduce the client's loneliness Correct4 Providing emotional support while demonstrating acceptance of the client Clients who have lost contact with reality can be helped to reestablish contact with reality when the nurse demonstrates respect and focuses on the client; this distracts the client's attention from the hallucinations. This client is responding to voices, not reality; setting limits is reality oriented and is usually ineffective unless it involves directing the client to dismiss the voices. The client represents no immediate threat to the self or others; isolating the client will decrease contact with reality and will probably worsen the hallucinations. Although this may lessen the hallucinations, it takes a long time to establish such a relationship and the client needs immediate help. 53%of students nationwide answered this question correctly. View Topics Confidence: Skipped Stats Issue with this question? 12. A nurse is caring for a client who is delusional and talking about people who are plotting to do harm. The staff members notice that the client is pacing more than usual, and the primary nurse concludes that the client is beginning to lose control. What is the most therapeutic nursing intervention? Correct1 Moving the client to a quiet place 2 Urging the client sit down for a short time 3 Encouraging the client to use a punching bag 4 Allowing the client to continue pacing under supervision Clients losing control feel frightened and threatened; they need external controls and a reduction in external stimuli. The client will be unable to sit at this time; the agitation is building. Encouraging the client to use a punching bag is helpful for pent-up aggressive behavior but not for agitation associated with delusions. The pacing is not adequately relieving the client's agitation. Another intervention is needed to prevent acting-out behaviors. Test-Taking Tip: The night before the examination you may wish to review some key concepts that you believe need additional time, but then relax and get a good night’s sleep. Remember to set your alarm, allowing yourself plenty of time to dress comfortably (preferably in layers, depending on the weather), have a good breakfast, and arrive at the testing site at least 15 to 30 minutes early. 72%of students nationwide answered this question correctly. View Topics Confidence: Skipped Stats Issue with this question? 13. A client who has been on a psychiatric unit for several weeks continually talks about delusional topics. What response by the nurse is most therapeutic? 1 Asking the client to explain the delusion 2 Allowing the client to maintain the delusion Correct3 Encouraging the client to focus on reality issues 4 Explaining to the client why the thoughts are not true Discussing reality-based issues helps decrease delusional and hallucinatory activity by reducing feelings of isolation and competition for sensory awareness. Asking the client to explain the delusions or allowing him to maintain them will support and reinforce the delusions and validate them. Explaining why the delusions are not true is a judgmental response that may decrease the client's trust and increase anxiety. 59%of students nationwide answered this question correctly. View Topics Confidence: Skipped Stats Issue with this question? 14. A nurse is planning activities for a withdrawn client who is hallucinating. What is the most therapeutic activity for this client? Correct1 Going for a walk with the nurse 2 Watching a movie with other clients 3 Playing a board game with a group of clients 4 Playing a game of cards alone in the dayroom Walking with the nurse facilitates one-on-one interaction and the development of a trusting relationship. Watching a movie will allow the client to withdraw further. Playing a game with others is beyond the client's ability at this time. Playing cards alone will allow the client to withdraw further. 73%of students nationwide answered this question correctly. View Topics Confidence: Skipped Stats Issue with this question? 15. A client who has a diagnosis of paranoid schizophrenia and has been violent in the past is admitted to the psychiatric unit. What should the nurse do before conducting an admission interview? 1 Move to the client's side and sit down. 2 Alert the assault response team about the client's history. 3 Have two other staff members present when talking with the client. Correct4 Enter the room with another staff member while remaining between the client and the door. Making sure to stay between the client and the door provides safety for the nurse and the other staff member because it will enable them to make a rapid exit. Moving to the client and sitting down invades the client's territory and may precipitate an aggressive client response. Alerting the assault response team is premature; the team is alerted when a client is out of control, harming self or others, and cannot be managed by the staff on the unit. Having two other staff members present may be viewed by the client as confrontational and may precipitate an aggressive response. 62%of students nationwide answered this question correctly. View Topics Confidence: Skipped Stats Issue with this question? 16. A client with schizophrenia, paranoid type, is readmitted to the hospital at the insistence of the family. While exploring her feelings about the readmission, the client angrily shouts, "You're one of them. Leave me alone." How should the nurse respond? 1 "Try not to be afraid. I won't hurt you." 2 "I'm not one of them—I'm here to help you." 3 "Your family and the staff are trying to help you." Correct4 "I can see that you're upset. We can talk more later." Acknowledging the client's feelings and offering an opportunity to talk in the future shows that the nurse cares and is not abandoning the client. Pursuing the topic while the client is angry may result in an escalation of the client's anger, jeopardizing the safety of the nurse and others. The nurse's telling the client that she is not one of "them" and that the client's family and staff are trying to help her requires trust on the part of the client, which may or may not be justified at this time; the client feels betrayed and is angry. 49%of students nationwide answered this question correctly. View Topics Confidence: Skipped Stats Issue with this question? 17. A nurse is caring for a client who is experiencing auditory hallucinations. What is the most therapeutic response by the nurse? 1 "Those voices you hear aren't real." Correct2 "I don't hear the voices you're hearing." 3 "Try to focus your attention on other things." 4 "You won't hear the voices when you get better." "I don't hear the voices you're hearing" points out reality without being demeaning or arguing with the client. The voices are real to the client, and stating otherwise will not be believed. Trying to focus the client's attention on other things is probably impossible. The client will be unable to focus on the future when attempting to cope with the frightening experience of hearing voices in the present; also, it may be false reassurance. 66%of students nationwide answered this question correctly. View Topics Confidence: Skipped Stats Issue with this question? 18. During a one-to-one interaction with a client with schizophrenia, paranoid type, the client says to the nurse, "I figured out how foreign agents have infiltrated the news media. They want to shut me up before I spill the beans." How should the nurse describe this statement? 1 Nihilistic delusion Correct2 Delusion of grandeur 3 Auditory hallucination 4 Overvaluation of the self Thoughts of being pursued by some powerful agent or agents because of one's special attributes or powers are fixed false beliefs and referred to as delusions of grandeur. There is no evidence to indicate that a delusion of total or partial nonexistence is being used. There is no evidence to indicate that a sensory-perceptual disturbance is present. Delusions of grandeur are usually used to deny unconscious feelings of low self-esteem. 57%of students nationwide answered this question correctly. View Topics Confidence: Skipped Stats Issue with this question? 19. A nurse is caring for a client with the diagnosis of schizophrenia. What should the nurse plan to do to increase the self-esteem of this client? Correct1 Reward healthy behaviors. 2 Explain the treatment plan. 3 Identify various means of coping. 4 Encourage participation in community meetings. By realistically rewarding the healthy behaviors, the nurse provides secondary gains and encourages the continued use of healthy behaviors. Explaining the treatment plan, identifying various means of coping, and encouraging participation in community meetings are important but will do little to increase the client's self-esteem. 61%of students nationwide answered this question correctly. View Topics Confidence: Skipped Stats Issue with this question? 20. When being admitted to a mental health facility, a young male adult tells the nurse that the voices he hears frighten him. The nurse knows that clients tend to hallucinate more vividly: 1 Before meals Correct2 After going to bed 3 During group activities 4 While watching television Auditory hallucinations are most troublesome when environmental stimuli are diminished and there are few competing distractions. Before meals, during group activities, and during television watching are all times of relatively high, competing environmental stimuli. A client with an inoperable temporal lobe tumor is experiencing frightening audio hallucinations, especially when alone. How can the nurse best help the client cope with these hallucinations? 1 By moving the client to a four-bed room closer to the nurses' station Correct2 By suggesting that the client turn on the radio or television when alone 3 By working out a schedule for visitors so the client will never be alone 4 By having family or friends remain with the client until the hallucinations stop Stimuli such as a television or radio encourage the client to remain reality oriented; research has shown that competing stimuli are useful in controlling hallucinations. Moving the client to a four-bed room closer to the nurses' station does not ensure that the client's needs will be met. Working out a schedule for visitors so the client will never be alone or having family or friends remain with the client until hallucinations stop is not realistic and fosters greater dependency; both solutions are focused on the client's inability to cope with the problem and will increase the client's fear of being alone. 50%of students nationwide answered this question correctly. View Topics Confidence: Skipped Stats Issue with this question? 2. A nurse plans to establish a trusting relationship with a client who is using paranoid ideation. How should the nurse begin to accomplish this? Correct1 By being available on the unit but waiting for the client to approach 2 By seeking the client out frequently to spend long blocks of time together 3 By sitting on the unit and observing the client's behavior throughout the day 4 By calling the client into the office to establish a contract for regular therapy sessions The recommended approach for working with suspicious clients is to allow them to set the pace of the relationship. It is less threatening if they are the one to initiate contact. Seeking the client out frequently to spend long blocks of time together, sitting and watching the client, and calling the client into the office may all be perceived as threatening and may add to feelings of paranoia. 53%of students nationwide answered this question correctly. View Topics Confidence: Skipped Stats Issue with this question? 3. A hospitalized psychiatric client with the diagnosis of histrionic personality disorder demands a sleeping pill before going to bed. After being refused the sleeping pill, the client throws a book at the nurse. The nurse identifies this behavior as: 1 Exploitive Correct2 Acting out 3 Manipulative 4 Reaction formation Acting out is the process of expressing feelings behaviorally. The action is not exploitive, because no evidence is provided to demonstrate that anyone has been used to get what the client wants. The action is not manipulative, because no evidence is provided to demonstrate that anyone has been influenced against his or her wishes. The action is not disguising unacceptable feelings by expressing opposite emotions. 69%of students nationwide answered this question correctly. View Topics Confidence: Skipped Stats Issue with this question? 4. A client with schizophrenia repeatedly says to the nurse, "No moley, jandu!" The nurse determines that the client is exhibiting: 1 Echolalia Correct2 Neologism 3 Concretism 4 Perseveration Neologisms are words that