Exam (elaborations) CLNS 101 Adaptive quiz Psychosis (CNLS101)

Exam (elaborations) CLNS 101 Adaptive quiz Psychosis (CNLS101) 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