A nurse is caring for a client who has schizophrenia. The client suddenly moves to the corner of the room and shouts, "Get it away from me!" Which of the following actions should the nurse take?

Tell the client that there is nothing there.

Ask the client to describe what is being seen.

Touch the client's arm reassuringly.

Remove the client from the room.

Answer and Explanation

The Correct Answer is B

A. Tell the client that there is nothing there. Dismissing the client's perception may increase distress and reduce trust in the nurse-client relationship. A therapeutic approach acknowledges the client’s experience without reinforcing or denying hallucinations.
B. Ask the client to describe what is being seen. Encouraging the client to describe the hallucination helps assess its nature and severity. Understanding the content allows the nurse to provide appropriate support, ensure safety, and guide interventions.
C. Touch the client's arm reassuringly. Touching the client without consent, especially during a distressing hallucination, may escalate fear or agitation. Maintaining a calm and non-threatening presence is more appropriate.
D. Remove the client from the room. Relocating the client without assessing the hallucination may not address the underlying distress. Identifying triggers and using therapeutic communication are more effective initial interventions.

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Correct Answer is C

Explanation

A. Borderline personality disorder. Borderline personality disorder falls under Cluster B, which includes dramatic, emotional, and erratic disorders. Individuals with this disorder often exhibit impulsivity, intense emotional instability, fear of abandonment, and unstable relationships.
B. Antisocial personality disorder. Antisocial personality disorder is part of Cluster B and is characterized by a disregard for social norms, lack of empathy, and manipulative or deceitful behavior. Individuals with this disorder often engage in impulsive and irresponsible actions.
C. Dependent personality disorder. Dependent personality disorder belongs to Cluster C, which includes anxious and fearful disorders. Individuals with this disorder exhibit excessive reliance on others, difficulty making decisions, and an intense fear of abandonment, leading to submissive and clingy behavior.
D. Paranoid personality disorder. Paranoid personality disorder is categorized under Cluster A, which consists of odd and eccentric personality disorders. It is characterized by pervasive distrust, suspicion of others, and a tendency to interpret others' actions as malicious.

A. Cyclothymic disorder B. Postpartum depression C. Premenstrual dysphoric disorder D. Bipolar disorder

Correct Answer is C

Explanation

A. Cyclothymic disorder: Cyclothymic disorder involves chronic mood instability with alternating hypomanic and depressive symptoms for at least two years. These mood fluctuations occur independently of the menstrual cycle and do not meet the criteria for major mood episodes.
B. Postpartum depression: Postpartum depression occurs within weeks to months after childbirth and presents with persistent sadness, fatigue, and emotional distress. It is unrelated to the menstrual cycle and requires medical treatment such as therapy and antidepressants.
C. Premenstrual dysphoric disorder: Premenstrual dysphoric disorder is marked by mood disturbances, including depressed mood, irritability, and anxiety, occurring in the luteal phase before menstruation. Symptoms resolve after menstruation begins, and treatment may include SSRIs, hormonal therapy, or lifestyle modifications.
D. Bipolar disorder: Bipolar disorder involves episodes of mania and depression that are unrelated to hormonal changes in the menstrual cycle. Manic episodes present with impulsivity and grandiosity, while depressive episodes cause low energy and anhedonia, requiring mood stabilizers.

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A nurse is caring for a client who has schizophrenia. The client suddenly moves to the corner of the room and shouts, "Get it away from me!" Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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