A female client who is a retired school teacher is admitted for a breast biopsy. After being told that the biopsy was positive for cancer, she becomes dependent and asks her family for help with activities of daily living that she is physically capable of performing. Which interpretation of this client's behavior by the nurse is likely to be most accurate?

Expected, as the client is attempting to reduce anxiety by regressing to a state of lesser anxiety.

Should be encouraged as representative of the client's non-destructive method of fear expression.

Unacceptable, and limits should be set to encourage the client to maintain her independence.

Should be accepted by staff as the first step the client must experience in the grieving process.

Answer and Explanation

The Correct Answer is A

A.   This behavior can be seen as a regression aimed at reducing anxiety during a stressful time, which is a relatively common psychological response to stress or trauma.
B.   While it may be a way for the client to cope, encouraging dependency might not necessarily be the best approach to fostering independence.
C.   While independence is important, setting rigid limits might not address the underlying emotional needs during a period of distress.
D.   Acknowledging and understanding the client's behavior as a coping mechanism within the grieving process can help the staff provide appropriate support and care.

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Correct Answer is B

Explanation

A. Role-playing might not be suitable for a hyperactive 4-year-old with potential autism, as their attention span and ability to engage in structured activities might be limited.
B. Adolescents often benefit from role-playing to navigate social situations and address feelings of rejection or lack of acceptance from peers.
C. Role-playing might not be as effective for an older adult in a long-term care facility who takes others' belongings, as this behavior may require different interventions.
D. While role-playing can be helpful for individuals with schizophrenia, their tendency to refuse medications might not necessarily be addressed through this method.

A. "The snakes on the wall are going to eat me." B. "The voices are telling me to kill the next person I see." C. "The nurse at night is trying to poison me with pills. D. "The fire is burning my skin away right now."

Correct Answer is C

Explanation

A. "The snakes on the wall are going to eat me" indicates a hallucination, specifically a visual hallucination. Hallucinations involve perceiving something that is not present, such as seeing or hearing things that others do not. This statement does not confirm delusions.

B. Hearing voices instructing harm doesn't confirm delusions but auditory hallucinations.

C. "The nurse at night is trying to poison me with pills" reflects a delusion, specifically a persecutory delusion. Delusions are false, fixed beliefs that are not based in reality and are resistant to reasoning or contradictory evidence. This statement indicates a belief that someone is attempting harm, which is characteristic of delusional thinking.

D. Believing fire is burning the skin could suggest a hallucination involving sensations, not necessarily a delusion.

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Naxlex Comprehensive Predictor Exams

The nurse plans to use role-playing as a therapeutic measure. Which individual is most likely to benefit from this type of therapeutic intervention?

Correct Answer is B

Explanation

The nurse documents that a male client with schizophrenia is delusional. Which statement by the client confirms this assessment?

Correct Answer is C

Explanation

A preschool-aged girl tells the school nurse that her hair hurts. The nurse finds that the child's hair has been arranged to cover several small bald spots. Which finding indicates to the nurse that the hair loss is not disease-related?

A female college student is admitted to the mental health unit following a drug overdose. The student tells the nurse that she took the overdose following the end of a romantic relationship. Which is the primary goal for hospitalization that should be included in this client's plan of care?

When the nurse addresses questions to an adult female client who is depressed, the client's responses are delayed. Which intervention should the nurse include in this client's plan of care?

A client with depression does not want to communicate with friends, uses television watching as a means of escaping responsibilities, and describes the inability to handle personal circumstances. Which coping strategy should the nurse include in the plan of care?

The nurse is using the CAGE questionnaire as a screening tool for a client who is seeking help because his wife said he had a drinking problem. Which information should the nurse explore in-depth with the client based on this screening tool?

The nurse is assessing a client who reports using cocaine several times in the past week.Which observations should the nurse expect on assessment?

The nurse is caring for a client who is experiencing extreme sadness after the passing of a companion of 30 years. The client describes not being able to think of other things and finds it difficult to control emotions. Which action should the nurse take first?