A client diagnosed with schizophrenia, on an inpatient unit, approaches a nurse, stating, "Someone took my dinner! People need to respect others, and you need to do something about this now!" Which response by the nurse is guided by the basic assumption of the therapeutic milieu?

"I can see that you are upset. Let's talk about ways to resolve this."

I'll fix this right away. You need to calm down."

"Let's find a way to avoid this conflict in the future."

"You should bring this up during group therapy later this week."

Answer and Explanation

The Correct Answer is A

a. "I can see that you are upset. Let's talk about ways to resolve this." This is correct because it validates the client's feelings, encourages problem-solving, and maintains the therapeutic milieu's principles of respect and support.
b. "I'll fix this right away. You need to calm down." This response does not encourage the client’s participation in resolving the issue and does not foster the therapeutic milieu's goal of client empowerment.
c. "Let's find a way to avoid this conflict in the future." While this promotes future problem-solving, it does not address the immediate concern or validate the client's current feelings.
d. "You should bring this up during group therapy later this week." This delays addressing the client's immediate concerns and might make the client feel unheard.

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Correct Answer is D

Explanation

a. Food is rapidly ingested without proper chewing: While this might happen in bulimia nervosa, it does not explain dental erosion.
b. Purging causes the depletion of dietary calcium: Calcium depletion could affect bones and teeth but is not the primary reason for the dental erosion seen in bulimia nervosa.
c. Poor dental and oral hygiene lead to dental caries: While poor hygiene can contribute to dental issues, the primary cause of dental deterioration in bulimia is the acid from vomiting.
d. Emesis from purging corrodes the tooth enamel. Frequent vomiting in bulimia nervosa exposes teeth to stomach acid, which erodes the enamel and leads to dental deterioration.

A. a client communicates significant distress. B. maladaptive responses to stress are coupled with interference in daily functioning. C. thoughts, feelings, and behaviors are not reflective of the DSM-5 criteria. D. a client uses defense mechanisms as ego protection.

Correct Answer is B

Explanation

a. a client communicates significant distress. While significant distress is important to consider, it alone does not necessarily indicate a risk for developing mental illness unless it also impacts daily functioning and coping mechanisms.
b. maladaptive responses to stress are coupled with interference in daily functioning. This choice is correct because it reflects a combination of maladaptive coping (which can exacerbate mental health issues) and interference with daily functioning (a key indicator of mental illness according to DSM-5 criteria).
c. thoughts, feelings, and behaviors are not reflective of the DSM-5 criteria. While alignment with DSM-5 criteria is crucial for diagnosis, this choice alone does not address the risk aspect. The focus should be on behaviors that lead to impairment in daily functioning and coping.
d. a client uses defense mechanisms as ego protection. Using defense mechanisms is a normal part of human behavior and not necessarily indicative of mental illness risk unless these mechanisms are maladaptive and interfere with functioning.

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A client diagnosed with schizophrenia, on an inpatient unit, approaches a nurse, stating, "Someone took my dinner! People need to respect others, and you need to do something about this now!" Which response by the nurse is guided by the basic assumption of the therapeutic milieu?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse observes dental deterioration when assessing a client diagnosed with Bulimia Nervosa. Which best explains this assessment finding

Correct Answer is D

Explanation

At what point should the nurse determine that a client is at risk for developing mental illness? When:

Correct Answer is B

Explanation

A client is noted to be pacing on the unit with their hands clenched and mumbling curses. The nurse knows that the initial approach to this client would be to:

Which of the following would be the best nursing action for a client who is having a panic attack?

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?

The nurse is giving discharge instructions to the family of a client diagnosed with a neurocognitive disorder. The nurse includes the client's family. Which statement by the family would indicate that teaching has been effective? The family states:

A nurse is caring for a client who is diagnosed with a conversion disorder. What actions should the nurse include in the plan of care?

A client diagnosed with vascular neurocognitive disorder (NCD) is discharged to home under the care of his wife. Which information should cause the nurse to question the client's safety?

A client has recently been diagnosed with Alzheimer's disease. Which medication would the nurse expect the physician to order for this client's cognitive impairment?

A client diagnosed with schizophrenia disorder states, "Can't you hear them? It's the devil. The devil is telling me I'm going to hell." Which is the most appropriate nursing response?