COMPLETE QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES.
A 38-year-old female client is admitted with a diagnosis of paranoid
schizophrenia. When her tray is brought to her, she refuses to eat and tells the
nurse, "I know you are trying to poison me with that food." Which response
would be 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 healthcare provider about the possibility of changing your
diet." - ANSWER-A.
.. A 19-year-old female client with a diagnosis of anorexia nervosa wants to help
serve dinner trays to other clients on a psychiatric unit. What action should the
nurse take?
A Encourage the client's self-motivation by asking her to pass trays for the rest
of the week.
B Provide an additional challenge by asking the client to help feed the older
clients.
C Suggest another way for this client to participate in the unit's activities.
,D Tell the client that hospital guidelines allow only staff to pass the trays. -
ANSWER-C
.. A 22-year-old male client is admitted to the emergency center following a
suicide attempt. His records reveal that this is his third suicide attempt in the
past two years. He is conscious, but does not respond to verbal commands for
treatment. Which assessment finding should prompt the nurse to prepare the
client for gastric lavage?
A He ingested the drug 3 hours prior to admission to the emergency center.
B The family reports that he took an entire bottle of acetaminophen (Tylenol).
C He is unresponsive to instructions and is unable to cooperate with emetic
therapy.
D Those with repeated suicide attempts desire punishment to relieve their guilt.
- ANSWER-C>
.. A 27-year-old female client is admitted to the psychiatric hospital with a
diagnosis 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. - ANSWER-D
.. A 30-year-old sales manager tells the nurse, "I am thinking about a job change.
I don't feel like I am living up to my potential." Which of Maslow's
developmental stages is the sales manager attempting to achieve?
A Self-Actualization.
B Loving and Belonging.
, C Basic Needs.
D Safety and Security. - ANSWER-A.
.. A 35-year-old male client on the psychiatric unit of a general hospital believes
that someone is trying to poison him. The nurse understands that a client's
delusions are most likely related to his
A early childhood experiences involving authority issues.
B anger about being hospitalized.
C low self-esteem.
D phobic fear of food. - ANSWER-C
.. A 35-year-old male client who has been hospitalized for two weeks for chronic
paranoia continues to state that someone is trying to steal his clothing. The
most appropriate action for the nurse to take is to
A encourage the client to actively participate in assigned activities on the unit.
B place a lock on the client's closet.
C ignore the client's paranoid ideation to extinguish these behaviors.
D explain to the client that his suspicions are false. - ANSWER-A
.. A 45-year-old male client tells the nurse that he used to believe that he was
Jesus Christ, but now he knows he is not. Which response is best for the nurse
to make?
A "Did you really believe you were Jesus Christ?"
B "I think you're getting well."
C "Others have had similar thoughts when under stress."
"Why did you think you were Jesus Christ?" - ANSWER-c