A nurse is caring for a client who has been diagnosed with schizophrenia and appears confused and has distortions in their thinking and speech patterns.

Which of the following is the priority nursing intervention for this client?

Ensure the client goes to group activities as planned.

Use distraction such as the television or music.

Provide reassurance and comfort ensuring the client is safe.

Give PRN medications to treat increased hallucinations.

Answer and Explanation

The Correct Answer is C

Choice A rationale:
Ensuring the client goes to group activities as planned is important, but not the priority when the client is confused and has distorted thinking.
Choice B rationale:
Using distraction such as television or music can be helpful, but it is not the priority intervention.
Choice C rationale:
Providing reassurance and comfort ensuring the client is safe is the priority as it directly addresses the client’s immediate needs.
Choice D rationale:
Giving PRN medications to treat increased hallucinations may be necessary, but it is not the first action to take.

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Correct Answer is C

Explanation

Choice A rationale:
Flooding therapy is not typically used for somatic symptom disorder.
Choice B rationale:
Telling a client that their pain is not real can invalidate their experience and is not a recommended approach for somatic symptom disorder.
Choice C rationale:
Providing reassurance to the client is a recommended approach when all tests are normal and there are no identified risk factors.
Choice D rationale:
Encouraging the client to request invasive cardiac testing is not typically recommended when all tests are normal and there are no identified risk factors.

A. "I know you hear the voices, but I do not.”. B. "The voices are part of your illness.”. C. "How often do you hear the voices?". D. "What are the voices telling you?".

Correct Answer is D

Explanation

Choice A rationale:

While acknowledging the voices can be part of therapeutic communication, it’s not the first response a nurse should make.

Choice B rationale:

Telling the client that the voices are part of their illness can be helpful, but it’s not the first response a nurse should make.

Choice C rationale:

Asking about the frequency of the voices can be part of the assessment, but it’s not the first response a nurse should make.

Choice D rationale:

Asking what the voices are saying can help assess if the client is experiencing command hallucinations, which could pose a safety risk.

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A nurse is caring for a client who has been diagnosed with schizophrenia and appears confused and has distortions in their thinking and speech patterns. Which of the following is the priority nursing intervention for this client?

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Correct Answer is C

Explanation

A nurse is caring for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following responses should the nurse make first?

Correct Answer is D

Explanation

A nurse is teaching a client who has bipolar disorder about lithium. Which of the following statements should the nurse include in the teaching?.

A nurse in an acute mental health unit is admitting a client who has bipolar disorder. Which of the following findings supports the admitting diagnosis of acute mania?

Which nursing intervention will have the greatest impact on both the management of care and on milieu environment when considering the clients diagnosed with bipolar disorder?

A nurse is reviewing abnormal laboratory values for four clients who have schizophrenia and take clozapine. For which of the following clients should the nurse withhold the medication and notify the provider immediately to have clozapine therapy discontinued?

A nurse is caring for a client who was recently diagnosed with somatic symptom disorder. The client says to the nurse, "I don't understand, they can't find anything medically wrong with me. I guess I will never feel better.”. Which of the following responses is the most therapeutic?

A nurse is reviewing the medical record of a client who performs self-injury. Which of the following information should the nurse identify as placing the client at risk for self-harm behaviors?

A nurse asks a client who is suicidal to make a safety contract, but the client declines. Which of the following actions should the nurse identify as the priority?.

A nurse is caring for a client who has been diagnosed with schizophrenia and appears confused and has distortions in their thinking and speech patterns.

Which of the following is the priority nursing intervention for this client?