A 16-year-old client diagnosed with schizophrenia disorder experiences command hallucinations to harm others. The client's parents ask a nurse, "Where do the voices come from?" Which is the appropriate nursing response?

"There is a chemical imbalance of the brain, which leads to altered perceptions."

"The hallucinations are caused by medication interactions."

"There is too little serotonin in the brain, causing delusions and hallucinations."

Abnormal hormonal changes have precipitated auditory hallucinations."

Answer and Explanation

The Correct Answer is A

a. "There is a chemical imbalance of the brain, which leads to altered perceptions." Schizophrenia is a complex mental health disorder with a strong biological component. While the exact cause is unknown, it's believed to involve abnormalities in brain chemistry and neurotransmitters. This is a general explanation that avoids going into too much detail but acknowledges the biological basis of hallucinations.
b. "The hallucinations are caused by medication interactions." Hallucinations are a core symptom of schizophrenia and not necessarily caused by medication interactions.
c. "There is too little serotonin in the brain, causing delusions and hallucinations." While serotonin might be involved in schizophrenia, it's not the only neurotransmitter implicated.
d. Abnormal hormonal changes have precipitated auditory hallucinations." Hormonal changes might influence mood, but they are not the primary cause of auditory hallucinations in schizophrenia.

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Correct Answer is ["D"]

Explanation

a. Blood pressure 110/70: This is within normal range for many individuals and is not immediately concerning in the post-operative context.
b. heart rate 86: This is a normal heart rate for most individuals and is not concerning post-operatively.
c. Hypoactive bowel sounds: Hypoactive bowel sounds are common post-operatively due to anesthesia and are not immediately concerning.
d. Increased restlessness Increased restlessness can be a sign of pain, anxiety, hypoxia, or other complications and should be addressed promptly.
e. Negative Homan's sign: A negative Homan’s sign indicates no apparent deep vein thrombosis and is a positive finding.

A. "The clonazepam is to be used for long term therapy in conjunction with buspirone." B. "Clonazepam is to be used short term until the buspirone takes full effect." C. "Buspirone can cause sedation and should be taken at night." D. "Tolerance could result with long term use of buspirone."

Correct Answer is B

Explanation

a. While buspirone can be used for long-term management, clonazepam is typically used for short periods.
b. This statement demonstrates the client understands clonazepam's short-term use for acute anxiety and buspirone's long-term role in managing GAD.
c. Buspirone doesn't typically cause drowsiness, unlike some other anxiety medications.
d. While tolerance can occur with some medications, buspirone is less likely to cause this compared to clonazepam.

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A 16-year-old client diagnosed with schizophrenia disorder experiences command hallucinations to harm others. The client's parents ask a nurse, "Where do the voices come from?" Which is the appropriate nursing response?

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Naxlex Comprehensive Predictor Exams

The nurse is assessing the status of a post-operative client in the PACU. The nurse should be most concerned with which assessment finding?

Correct Answer is ["D"]

Explanation

A client diagnosed with General Anxiety Disorder (GAD) is started on clonazepam and buspirone. Which statement made by the client indicates teaching has been effective? The client verbalizes that:

Correct Answer is B

Explanation

A 16-year-old client diagnosed with schizophrenia disorder experiences command hallucinations to harm others. The client's parents ask a nurse, "Where do the voices come from?" Which is the appropriate nursing response?

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