A nurse is caring for a client who has bipolar disorder. The client says to the nurse, “Give me your pen to cut the pain out of my chest.” The nurse should identify that the client is at risk for which of the following?

Illusion

Hallucination

Attention-seeking behavior

Self-mutilation

Answer and Explanation

The Correct Answer is D

Choice A reason:
An illusion is a misinterpretation of a real external stimulus. For example, seeing a shadow and thinking it is a person. The client’s statement does not indicate a misinterpretation of reality but rather a desire to inflict harm on themselves.
Choice B reason:
A hallucination is a false sensory perception without any real external stimulus, such as hearing voices or seeing things that are not there. The client’s statement does not suggest they are experiencing a hallucination but rather expressing a desire to self-harm.
Choice C reason:
Attention-seeking behavior involves actions taken to gain attention from others. While the client’s statement could be seen as a cry for help, it is more accurately identified as a risk for self-mutilation due to the explicit mention of wanting to cut themselves.
Choice D reason:
Self-mutilation refers to deliberate self-inflicted harm, often as a way to cope with emotional pain. The client’s statement, “Give me your pen to cut the pain out of my chest,” clearly indicates a risk for self-mutilation, as they are expressing a desire to harm themselves to alleviate emotional distress.

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Correct Answer is ["C","E","F"]

Explanation

Choice A reason:

Impaired interpersonal relationships can be a consequence of schizophrenia, but it is not a specific diagnostic criterion in the DSM-5. The criteria focus on more direct symptoms of the disorder.

Choice B reason:

Inability to initiate activities may be related to negative symptoms of schizophrenia, such as avolition, but it is not explicitly listed as a diagnostic criterion in the DSM-5. The criteria include more specific symptoms like disorganized behavior and hallucinations.

Choice C reason:

Disorganized behavior is one of the core symptoms of schizophrenia according to the DSM-5. It includes behaviors that are inappropriate or not goal-directed, reflecting a disruption in normal functioning.

Choice D reason:

Antisocial personality is a separate diagnosis and not a criterion for schizophrenia. Schizophrenia and antisocial personality disorder are distinct conditions with different diagnostic criteria.

Choice E reason:

Hallucinations are a key symptom of schizophrenia. They involve perceiving things that are not present, such as hearing voices or seeing things that others do not see. Hallucinations are one of the primary positive symptoms of schizophrenia.

Choice F reason:

Lack of emotional expression, also known as affective flattening, is a negative symptom of schizophrenia. It involves a reduced ability to express emotions and is a significant criterion in the diagnosis of schizophrenia.

A. Put the client in a quiet room B. Teach the client deep breathing C. Remain with the client D. Encourage the client to talk about their feelings and concerns

Correct Answer is C

Explanation

Choice A reason:
Putting the client in a quiet room can help reduce external stimuli and may be beneficial in managing anxiety. However, it does not address the immediate need for support and reassurance. The presence of a nurse can provide a sense of safety and help the client feel more secure during a highly anxious state.

Choice B reason:
Teaching the client deep breathing techniques is an effective strategy for managing anxiety. However, in the immediate aftermath of a traumatic event, the client may not be able to focus on learning new techniques. Providing immediate support and reassurance is more critical at this stage.

Choice C reason:
Remaining with the client is the most appropriate immediate intervention. The nurse’s presence can provide comfort, reassurance, and a sense of safety, which are crucial in managing acute anxiety. This approach helps to stabilize the client and allows for further assessment and intervention once the client is calmer.

Choice D reason:
Encouraging the client to talk about their feelings and concerns is an important part of anxiety management, but it may not be the best immediate intervention in a severe state of anxiety. Initially, the client may need more direct support and reassurance before they are able to articulate their feelings effectively. Once the client is calmer, discussing their feelings can be beneficial.

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A nurse is caring for a client who has bipolar disorder. The client says to the nurse, “Give me your pen to cut the pain out of my chest.” The nurse should identify that the client is at risk for which of the following?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the DSM-5 diagnostic criteria for schizophrenia. Which of the following symptoms must be present for a client to be diagnosed with schizophrenia? (Select all that apply.)

Correct Answer is ["C","E","F"]

Explanation

A woman comes into the Emergency Department in a severe state of anxiety following a car accident. The appropriate nursing intervention is to:

Correct Answer is C

Explanation

A nurse is preparing to discharge a client who has been diagnosed with schizophrenia. The client asks, “I am not sure why I need to have a relapse plan.” Which of the following responses should the nurse make?

A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the nurse take?

A nurse is caring for a client who has been diagnosed with schizophrenia. The client has been wearing the same clothes for the past week and appears unkempt and unbathed. Which of the following statements should the nurse make to the client?

A nurse is interviewing a client who is experiencing negative symptoms of psychosis about their family history of schizophrenia. In which of the following phases of the nursing process should this take place?

A nurse is performing an admission assessment for a client who has schizophrenia. Which of the following findings should the nurse identify as a negative symptom?

While working with an older client, a nurse begins to think of the client as a grandparent and responds to the client as a grandchild. The nurse is developing what type of emotional reaction?

After being scolded by his supervisor at work, a man comes home and punches several holes in his walls and yells at his significant other. Which of the following defense mechanisms does this scenario depict?