A middle-aged female client with no previous psychiatric history is seen in the mental health clinic because her family describes her as having paranoid thoughts. On assessment, she tells the nurse, "I want to find out why these people are stalking me!" Which response should the nurse provide?

"Do you think someone is trying to harm you?"

"What makes you think people are stalking you?"

"It sounds like this experience is frightening for you."

"I know you are frightened, but no one is stalking you."

Answer and Explanation

The Correct Answer is B

Choice A rationale: "Do you think someone is trying to harm you?" is a leading question and may contribute to the client's paranoid thoughts. It is important to explore the client's concerns without making assumptions.

Choice B rationale: "What makes you think people are stalking you?" is an open-ended question that invites the client to share more about her experiences and thought processes. It allows for a deeper exploration of the client's perceptions.

Choice C rationale: "It sounds like this experience is frightening for you" is a closed statement and may not encourage the client to elaborate on her thoughts. Open-ended questions are more effective in this situation.

Choice D rationale: "I know you are frightened, but no one is stalking you" is a dismissive statement that may invalidate the client's feelings. It is imp

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Correct Answer is A

Explanation

Choice A rationale: Abrupt discontinuation of alprazolam, a benzodiazepine used to treat anxiety disorders, can lead to withdrawal symptoms, including rebound anxiety,

insomnia, and potentially seizures. The statement reflects an understanding of the importance of gradual tapering and not abruptly stopping the medication. Choice B rationale: Reporting side effects such as dizziness, lightheadedness, or sedation is important, but the key focus for long-term benzodiazepine use is the need to avoid abrupt discontinuation.

Choice C rationale: While attending therapy sessions is beneficial for managing anxiety, the question is specifically addressing the self-care goal related to medication use. Choice D rationale: Reporting any decrease in anxiety using a 10-point scale is relevant but not as crucial as emphasizing the avoidance of abrupt discontinuation.

A. Administer an antianxiolytic medication. B. Insert fecal management tube. C. Insert peripheral intravenous catheter. D. Crush pills and place in applesauce.

Correct Answer is C

Explanation

Choice A rationale: Administering an antianxiolytic medication may be appropriate, but addressing the client's fluid and electrolyte imbalance is the priority.

Choice B rationale: Inserting a fecal management tube is not the first action to take in response to hemoccult positive liquid stools; addressing fluid balance is more urgent.

Choice C rationale: Inserting a peripheral intravenous catheter is the priority to address the client's fluid and electrolyte imbalance and provide necessary hydration and medications.

Choice D rationale: Crushing pills and placing them in applesauce may be considered, but the client's fluid and electrolyte imbalance needs prompt attention first.

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A middle-aged female client with no previous psychiatric history is seen in the mental health clinic because her family describes her as having paranoid thoughts. On assessment, she tells the nurse, "I want to find out why these people are stalking me!" Which response should the nurse provide?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing a client for discharge who has been taking alprazolam long-term for generalized anxiety disorder (GAD). When evaluating the client's grasp of the discharge teaching, which statement made by the client shows an understanding of the most important self-care goal?

Correct Answer is A

Explanation

Two days after being admitted with alcohol withdrawal, a client has constant liquid stools and abdominal cramping. The emesis and stool are hemoccult positive. The client is confused and refusing to take oral medication. Which action should the nurse implement first?

Correct Answer is C

Explanation

A client who is experiencing a severe level of anxiety and reports a racing heartbeat, dizziness, and expresses a sense that something dreadful will happen. The nurse observes the client pacing and waving hands rapidly. Which action should the nurse take?

A young adult client is admitted to a psychiatric facility with a diagnosis of bulimia nervosa. Which nursing intervention has the highest priority?

The nurse is assessing a client with postpartum depression for changes in the mood and cognitive state. Which subjective finding(s) should the nurse identify that are consistent with postpartum depression? Select all that apply.

During a high school class on substance abuse, a student tells the group, "If I tried cocaine, I know I could handle it. I know when to stop." Which response is best for the nurse to provide?

After several days of being despondent and nonverbal, a female client with depression begins to talk and exhibit energy. Which action should the nurse implement?

A young woman is preparing to be discharged from the psychiatric unit. Which nursing intervention is most important for the nurse to Include in this phase of the nurse-client relationship?