NR 326 Exam #3 Questions With Complete Solutions
A nurse in an acute mental health facility is creating a plan
of care for a new client who has a co-occurring histrionic
personality disorder. Which of the following is the priority
intervention for the nurse to make?
A. Promote appropriate behavior during group therapy sessions.
B. Encourage client input in the treatment plan.
C. Communicate with the client using concrete language.
D. Demonstrate assertive behavior.
A. Promote appropriate behavior during group therapy sessions.
Rationale: Managing the client's behavior within the group is the
priority intervention for the client who has histrionic personality
disorder because these clients display extreme attention-seeking
behaviors and are often impulsive, which can be extremely
disruptive in a group setting with other members.
A nurse is providing discharge teaching for a client who has
schizophrenia and a new prescription for iloperidone. Which
of the following client statements indicates understanding of
the teaching?
A. “I will be able to stop taking this medication as soon as I feel
better.”
,B. “If I feel drowsy during the day, I will stop taking this
medication and call my provider.”
C. “I will be careful not to gain too much weight while taking
this medication.”
D. “This medication is highly addictive and must be withdrawn
slowly.”
A. Antipsychotic medications are considered a long‐term
treatment for schizophrenia. Discontinuing the medication can
result in an exacerbation of manifestations.
B. Drowsiness is a common adverse effect of antipsychotic
medications. However, it is not appropriate to discontinue the
medication.
C. CORRECT: Antipsychotic medications (iloperidone) have a
high risk for significant weight gain.
D. Antipsychotic medications are not considered addictive, and
it is not necessary to titrate iloperidone when discontinuing
treatment.
A nurse is completing an admission assessment for a client
who has schizophrenia. Which of the following findings
should the nurse document as positive symptoms? (Select all
that apply.)
A. Auditory hallucination
B. Lack of motivation
C. Use of clang associations
,D. Delusion of persecution
E. Constantly waving arms
F. Flat affect
A. CORRECT: Hallucinations are an example
of a positive symptom.
B. Lack of motivation, or avolition, is an
example of a negative symptom.
C. CORRECT: Alterations in speech are an
example of a positive symptom.
D. CORRECT: Delusions are an example of a positive
symptom.
E. CORRECT: Bizarre motor movements are an example of a
positive symptom.
F. Flat affect is an example of a negative symptom.
A nurse is caring for a client who has schizoaffective
disorder. Which of the following statements indicates the
client is experiencing depersonalization?
A. “I am a superhero and am immortal.”
B. “I am no one, and everyone is me.”
C. “I feel monsters pinching me all over.”
D. “I know that you are stealing my thoughts.”
, A. This comment indicates the client is experiencing delusions
of grandeur.
B. CORRECT: This comment indicates the client is
experiencing a loss of identity or depersonalization.
C. This comment indicates the client is experiencing a tactile
hallucination.
D. This comment indicates the client is
experiencing thought withdrawal.
A nurse is caring for a client on an acute mental health unit.
The client reports hearing voices that are stating, “kill your
doctor.” Which of the following actions should the nurse
take first?
A. Encourage the client to participate in group therapy on the
unit.
B. Initiate one‐to‐one observation of the client.
C. Focus the client on reality.
D. Notify the provider of the client’s statement.
A. Encourage the client to participate in group therapy to assist
with reality testing and to increase coping skills. However there
is another action to take first.
B. CORRECT: A client who is experiencing a command
hallucination is at risk for injury to self or others. Safety is the
priority, and initiating one‐to‐one observationis the first action
the nurse should take.
A nurse in an acute mental health facility is creating a plan
of care for a new client who has a co-occurring histrionic
personality disorder. Which of the following is the priority
intervention for the nurse to make?
A. Promote appropriate behavior during group therapy sessions.
B. Encourage client input in the treatment plan.
C. Communicate with the client using concrete language.
D. Demonstrate assertive behavior.
A. Promote appropriate behavior during group therapy sessions.
Rationale: Managing the client's behavior within the group is the
priority intervention for the client who has histrionic personality
disorder because these clients display extreme attention-seeking
behaviors and are often impulsive, which can be extremely
disruptive in a group setting with other members.
A nurse is providing discharge teaching for a client who has
schizophrenia and a new prescription for iloperidone. Which
of the following client statements indicates understanding of
the teaching?
A. “I will be able to stop taking this medication as soon as I feel
better.”
,B. “If I feel drowsy during the day, I will stop taking this
medication and call my provider.”
C. “I will be careful not to gain too much weight while taking
this medication.”
D. “This medication is highly addictive and must be withdrawn
slowly.”
A. Antipsychotic medications are considered a long‐term
treatment for schizophrenia. Discontinuing the medication can
result in an exacerbation of manifestations.
B. Drowsiness is a common adverse effect of antipsychotic
medications. However, it is not appropriate to discontinue the
medication.
C. CORRECT: Antipsychotic medications (iloperidone) have a
high risk for significant weight gain.
D. Antipsychotic medications are not considered addictive, and
it is not necessary to titrate iloperidone when discontinuing
treatment.
A nurse is completing an admission assessment for a client
who has schizophrenia. Which of the following findings
should the nurse document as positive symptoms? (Select all
that apply.)
A. Auditory hallucination
B. Lack of motivation
C. Use of clang associations
,D. Delusion of persecution
E. Constantly waving arms
F. Flat affect
A. CORRECT: Hallucinations are an example
of a positive symptom.
B. Lack of motivation, or avolition, is an
example of a negative symptom.
C. CORRECT: Alterations in speech are an
example of a positive symptom.
D. CORRECT: Delusions are an example of a positive
symptom.
E. CORRECT: Bizarre motor movements are an example of a
positive symptom.
F. Flat affect is an example of a negative symptom.
A nurse is caring for a client who has schizoaffective
disorder. Which of the following statements indicates the
client is experiencing depersonalization?
A. “I am a superhero and am immortal.”
B. “I am no one, and everyone is me.”
C. “I feel monsters pinching me all over.”
D. “I know that you are stealing my thoughts.”
, A. This comment indicates the client is experiencing delusions
of grandeur.
B. CORRECT: This comment indicates the client is
experiencing a loss of identity or depersonalization.
C. This comment indicates the client is experiencing a tactile
hallucination.
D. This comment indicates the client is
experiencing thought withdrawal.
A nurse is caring for a client on an acute mental health unit.
The client reports hearing voices that are stating, “kill your
doctor.” Which of the following actions should the nurse
take first?
A. Encourage the client to participate in group therapy on the
unit.
B. Initiate one‐to‐one observation of the client.
C. Focus the client on reality.
D. Notify the provider of the client’s statement.
A. Encourage the client to participate in group therapy to assist
with reality testing and to increase coping skills. However there
is another action to take first.
B. CORRECT: A client who is experiencing a command
hallucination is at risk for injury to self or others. Safety is the
priority, and initiating one‐to‐one observationis the first action
the nurse should take.
