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

Explanation

Choice A reason:
Schizophrenia is rarely diagnosed in preschool-aged children. Early-onset schizophrenia can occur, but it is extremely uncommon in this age group.
Choice B reason:
While schizophrenia can develop in school-age children, it is still relatively rare. The typical age of onset is later, during adolescence or young adulthood.
Choice C reason:
Young adulthood is the most common age group for the onset of schizophrenia. Symptoms often begin to appear in late adolescence to early adulthood, typically between the ages of 16 and 30.
Choice D reason:
Schizophrenia is not typically diagnosed in older adulthood. While older adults can experience symptoms of schizophrenia, the onset of the disorder usually occurs much earlier in life.

A. Assist the staff in caring for the client in a controlled environment B. Provide safety for the client and other clients on the unit C. Provide the clients on the unit with a sense of comfort and safety D. Offer the client a less stimulated area to calm down and gain control

Correct Answer is B

Explanation

Choice A reason:
While assisting the staff in caring for the client in a controlled environment is important, the immediate priority is to ensure safety. This choice does not directly address the immediate need to protect all clients from potential harm.

Choice B reason:
Providing safety for the client and other clients on the unit is the immediate priority. The client’s aggressive behavior poses a risk to themselves and others, and ensuring safety is the first step in managing the situation. This involves de-escalation techniques and possibly removing the client from the group setting to prevent harm.

Choice C reason:
Providing a sense of comfort and safety is important but secondary to ensuring immediate physical safety. The client’s aggressive behavior needs to be managed first to prevent any potential harm.

Choice D reason:
Offering the client a less stimulated area to calm down is a good strategy for de-escalation, but it comes after ensuring the immediate safety of all clients. The primary concern is to prevent any aggressive actions that could harm others.

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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 providing education to a group of staff members about schizophrenia. Which of the following age groups should the nurse include as the age when schizophrenia is typically diagnosed?

Correct Answer is C

Explanation

During group therapy, the nurse observes that a client is pacing, agitated, and presenting with aggressive gestures. The client’s speech pattern is rapid, and affect is belligerent. Based on the observations, the nurse’s immediate priority of care is to:

Correct Answer is B

Explanation

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