RN Hesi Case Study - Psychosis question & answers 2023

RN Hesi Case Study - PsychosisWhich thought process describes the client's inability to leave his apartment because he thinks someone is waiting to kill him? A. Hallucination. B. Phobia. C. Delusions. D. Confabulation. - correct answer C. Delusions. When the client explains that someone has been following him and is waiting outside the door of the ED, how should the nurse respond? - Insist that no one has followed the client there. - State how he must be concerned and assure him he will be safe there. - Tell the client that the police will make sure no one is out there. - Ask the client why he thinks that someone is out there. - correct answer State how he must be concerned and assure him he will be safe there. The nurse observes the client looking to the corner of the room and mumbling to himself. Which intervention is most important for the nurse to include in the client's plan of care? - Encourage the client to share the meaning of their delusions. - Interview the client to identify his feelings of depersonalization. - Begin a sequence of interventions to address the client's hallucinations. - Orient the client to their place and situation. - correct answer - Begin a sequence of interventions to address the client's hallucinations. (Hallucinations can be nonverbal or they can include talking to oneself, moving the lips without making sounds, rapid eye movements, and grinning or inappropriate laughter.) When the client looks around the room and mumbles to himself, how should the nurse respond? - Have the client express how he is feeling. - Ask the client if they are hearing voices. - See if the client recalls being here before. - Tell the client to say what they are thinking. - correct answer - Ask the client if they are hearing voices. The client admits that the voices he hears have been getting louder over the past couple of weeks. Which nursing intervention best promotes effective communication? - Ask the client what helps the voices go away. - Determine how long the client has been hearing voices. - Document when the voices began getting louder. - Have the client repeat what he thinks the voices are saying. - correct answer - Have the client repeat what he thinks the voices are saying. Which medications should the nurse anticipate giving the client after securing a prescription from the healthcare provider? (Select all that apply. One, some, or all options may be correct.) A. Short-acting anxiolytic (benzodiazepines). B. Antipsychotic medication. C. Mood-stabilizing medication. D. Nonbenzodiazepine anxiolytic (antianxiety agent). E. Antidepressant. - correct answer A. Short-acting anxiolytic (benzodiazepines). B. Antipsychotic medication. Which assessment data provides evidence that the client can be involuntarily committed to the hospital, if he insists on leaving? A. Past history of suicide attempts. B. Losing 10 pounds in 2 weeks. C. Auditory hallucinations. D. Persecutory delusions. - correct answer B. Losing 10 pounds in 2 weeks.