NURS 129 Exam 2 Questions With Correct
Answers
1. After the initial assessment of a patient diagnosed with schizoaffective
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disorder, the nurse identifies "Self-care deficit" as a nursing diagnosis based on
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the following assessment data.
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A. The pt exhibits poor concentration and attention
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B. The patient presents with disheveled appearance
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C. The pt identifies difficulty in maintaining their home in a safe and comfortable
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condition
D. The pt exhibits loose association of ideas - CORRECT ANSWER✔✔-B. The
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patient presents with disheveled appearance
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rationale: This assessment finding indicates the pt's inability to independently
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perform self-care activities such as hygiene, eating, toileting, dressing.
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2. The nurse is caring for a college student who started hearing voices, has not
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attended classes for the past 4 weeks, was yelling accusations at others, and has
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stopped communicating with family and friends. Which is the nurse's priority
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nursing diagnosis?|
A. Risk of other-directed violence R/T yelling accusations
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B. Altered thought processes R/T hearing voices AEB increased anxiety
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C. Risk of self-directed violence R/T depressed mood
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,D. Social isolation R/T paranoia AEB absence from classes - CORRECT
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ANSWER✔✔-A. Risk of other-directed violence R/T yelling accusations
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rationale: Safety is always the priority. Verbal aggression is a behavior indicating
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risk of violence. Other risk factors include aggressive body language, command
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hallucinations, rage reactions, and destruction of objects in the environment.
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3. A pt diagnosed with schizoaffective disorder presents with auditory and visual
| | | | | | | | | | | |
hallucinations, circumstantial thought process, and blunted affect. What would
| | | | | | | | |
the nurse's priority assessment?
| | |
A. "What psychiatric medications are you currently taking?"
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B. "Have you taken any drugs or alcohol recently?"
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C. "What are the voices saying to you?"
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D. "Are you having any thoughts about hurting other?" - CORRECT ANSWER✔✔-
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C. "What are the voices saying to you?"
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rationale: Based on the information given, the priority would be to assess the
| | | | | | | | | | | | |
content of the hallucinations, which will include any command hallucinations.
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4. Which client is most likely to benefit from group therapy?
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A. A client diagnosed with schizophrenia being followed up on in an out-patient
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clinic
B. A client diagnosed with schizophrenia who is not adherent with antipsychotic
| | | | | | | | | | | |
medications
C. A client experiencing an exacerbation of the signs and symptoms of
| | | | | | | | | | | |
schizophrenia
, D. A client with schizophrenia is newly admitted to an in-patient unit for
| | | | | | | | | | | | |
stabilization. - CORRECT ANSWER✔✔-A. A client diagnosed with schizophrenia
| | | | | | | | |
being followed up on in an out-patient clinic
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5. A client is in the active phase of schizophrenia and is experiencing paranoid
| | | | | | | | | | | | | |
thinking. Which nursing intervention would aid in facilitating other interventions?
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A. Encourage participation in group activities
| | | | |
B. Convey acceptance of the client's delusional belief
| | | | | | |
C. Assign consistent staff members.
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D. Help the client understand that anxiety causes hallucinations. - CORRECT
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ANSWER✔✔-C. Assign consistent staff members. | | | |
6. A client taking olanzapine (Zyprexa) has a nursing diagnosis of altered sensory
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perception would be appropriate for this client's problem?
| | | | | | |
A. The client will limit caloric intake because of the side effect of weight gain.
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B. The client will verbalize feelings related to depression and suicidal ideations.
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C. The client will tell staff members if experiencing thoughts of self-harm.
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D. The client will notify staff members of bothersome hallucinations. - CORRECT
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ANSWER✔✔-D. The client will notify staff members of bothersome | | | | | | | | |
hallucinations. |
rationale: When the client has the insight to recognize hallucinations and report
| | | | | | | | | | | |
them to staff members, the client is in better touch with reality and moving
| | | | | | | | | | | | | |
toward remission. This is an outcome that relates to the client's problem of
| | | | | | | | | | | | |
altered sensory perception. Reporting to staff members also can assist in
| | | | | | | | | | |
preventing the client from following through with the commands given by
| | | | | | | | | | |
auditory hallucinations
|
Answers
1. After the initial assessment of a patient diagnosed with schizoaffective
| | | | | | | | | | |
disorder, the nurse identifies "Self-care deficit" as a nursing diagnosis based on
| | | | | | | | | | | |
the following assessment data.
| | | |
A. The pt exhibits poor concentration and attention
| | | | | | |
B. The patient presents with disheveled appearance
| | | | | |
C. The pt identifies difficulty in maintaining their home in a safe and comfortable
| | | | | | | | | | | | | |
condition
D. The pt exhibits loose association of ideas - CORRECT ANSWER✔✔-B. The
| | | | | | | | | | | |
patient presents with disheveled appearance
| | | |
rationale: This assessment finding indicates the pt's inability to independently
| | | | | | | | | |
perform self-care activities such as hygiene, eating, toileting, dressing.
| | | | | | | |
2. The nurse is caring for a college student who started hearing voices, has not
| | | | | | | | | | | | | | |
attended classes for the past 4 weeks, was yelling accusations at others, and has
| | | | | | | | | | | | | |
stopped communicating with family and friends. Which is the nurse's priority
| | | | | | | | | | |
nursing diagnosis?|
A. Risk of other-directed violence R/T yelling accusations
| | | | | | |
B. Altered thought processes R/T hearing voices AEB increased anxiety
| | | | | | | | | |
C. Risk of self-directed violence R/T depressed mood
| | | | | | |
,D. Social isolation R/T paranoia AEB absence from classes - CORRECT
| | | | | | | | | | |
ANSWER✔✔-A. Risk of other-directed violence R/T yelling accusations
| | | | | | |
rationale: Safety is always the priority. Verbal aggression is a behavior indicating
| | | | | | | | | | | |
risk of violence. Other risk factors include aggressive body language, command
| | | | | | | | | | |
hallucinations, rage reactions, and destruction of objects in the environment.
| | | | | | | | |
3. A pt diagnosed with schizoaffective disorder presents with auditory and visual
| | | | | | | | | | | |
hallucinations, circumstantial thought process, and blunted affect. What would
| | | | | | | | |
the nurse's priority assessment?
| | |
A. "What psychiatric medications are you currently taking?"
| | | | | | |
B. "Have you taken any drugs or alcohol recently?"
| | | | | | | |
C. "What are the voices saying to you?"
| | | | | | |
D. "Are you having any thoughts about hurting other?" - CORRECT ANSWER✔✔-
| | | | | | | | | | |
C. "What are the voices saying to you?"
| | | | | | |
rationale: Based on the information given, the priority would be to assess the
| | | | | | | | | | | | |
content of the hallucinations, which will include any command hallucinations.
| | | | | | | | |
4. Which client is most likely to benefit from group therapy?
| | | | | | | | | |
A. A client diagnosed with schizophrenia being followed up on in an out-patient
| | | | | | | | | | | | |
clinic
B. A client diagnosed with schizophrenia who is not adherent with antipsychotic
| | | | | | | | | | | |
medications
C. A client experiencing an exacerbation of the signs and symptoms of
| | | | | | | | | | | |
schizophrenia
, D. A client with schizophrenia is newly admitted to an in-patient unit for
| | | | | | | | | | | | |
stabilization. - CORRECT ANSWER✔✔-A. A client diagnosed with schizophrenia
| | | | | | | | |
being followed up on in an out-patient clinic
| | | | | | |
5. A client is in the active phase of schizophrenia and is experiencing paranoid
| | | | | | | | | | | | | |
thinking. Which nursing intervention would aid in facilitating other interventions?
| | | | | | | | |
A. Encourage participation in group activities
| | | | |
B. Convey acceptance of the client's delusional belief
| | | | | | |
C. Assign consistent staff members.
| | | |
D. Help the client understand that anxiety causes hallucinations. - CORRECT
| | | | | | | | | | |
ANSWER✔✔-C. Assign consistent staff members. | | | |
6. A client taking olanzapine (Zyprexa) has a nursing diagnosis of altered sensory
| | | | | | | | | | | | |
perception would be appropriate for this client's problem?
| | | | | | |
A. The client will limit caloric intake because of the side effect of weight gain.
| | | | | | | | | | | | | |
B. The client will verbalize feelings related to depression and suicidal ideations.
| | | | | | | | | | |
C. The client will tell staff members if experiencing thoughts of self-harm.
| | | | | | | | | | |
D. The client will notify staff members of bothersome hallucinations. - CORRECT
| | | | | | | | | | | |
ANSWER✔✔-D. The client will notify staff members of bothersome | | | | | | | | |
hallucinations. |
rationale: When the client has the insight to recognize hallucinations and report
| | | | | | | | | | | |
them to staff members, the client is in better touch with reality and moving
| | | | | | | | | | | | | |
toward remission. This is an outcome that relates to the client's problem of
| | | | | | | | | | | | |
altered sensory perception. Reporting to staff members also can assist in
| | | | | | | | | | |
preventing the client from following through with the commands given by
| | | | | | | | | | |
auditory hallucinations
|
