A nurse is caring for a young adult client who has acute schizophrenic disorder and tells the nurse, "Yesterday noon the sun moon went over the rover to see the lawnmower.”. Which of the following manifestations is the client exhibiting?

Delusional disorder.

Anhedonia.

Associative looseness.

Hallucination.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Delusional disorder is characterized by the presence of one or more delusions for a month or longer, which could be plausible but are not real. This is not the case here.

Choice B rationale:

Anhedonia refers to the inability to experience pleasure, a common symptom in many mental disorders, including depression. It does not apply to this situation.

Choice C rationale:

Associative looseness, or loose associations, is a thought disorder characterized by speech in which ideas shift from one subject to another that is unrelated or minimally related. The client’s statement is an example of this.

Choice D rationale:

Hallucinations are sensory experiences that occur in the absence of actual stimulation. The client’s statement is not a hallucination, but a disorganized thought process.

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Correct Answer is B

Explanation

Choice A rationale:

Discouraging clients from discussing NSSH with friends may not be beneficial. Open communication can provide support and understanding.

Choice B rationale:

Early recognition is crucial to successful treatment. Timely intervention can prevent the escalation of self-harm behaviors and facilitate recovery.

Choice C rationale:

Recognizing NSSH as an attention-seeking behavior can be a misconception. NSSI is a complex behavior often associated with various underlying issues like emotional distress.

Choice D rationale:

Asking the client why they do this as soon as possible may not always be helpful. The focus should be on understanding their feelings and providing support.

A. Have consistent unit routines. B. Provide a stimulating environment. C. Schedule daily seclusion times. D. Discourage daytime napping.

Correct Answer is A

Explanation

Choice A rationale:
Having consistent unit routines can provide a sense of stability and predictability, which can be beneficial for a client in the manic phase of bipolar disorder.
Choice B rationale:
Providing a stimulating environment can potentially exacerbate symptoms of mania, making it an inappropriate intervention.
Choice C rationale:
Scheduling daily seclusion times is not typically recommended as it can lead to feelings of isolation.
Choice D rationale:
Discouraging daytime napping can potentially lead to fatigue and worsen symptoms, so it’s not typically recommended.

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A nurse is caring for a young adult client who has acute schizophrenic disorder and tells the nurse, "Yesterday noon the sun moon went over the rover to see the lawnmower.”. Which of the following manifestations is the client exhibiting?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is conducting an in-service for a group of newly licensed nurses about the interventions used for clients experiencing non-suicidal self-harm (NSSH). Which of the following should the nurse include?.

Correct Answer is B

Explanation

A nurse is planning care for a client who is in the manic phase of bipolar disorder. Which of the following interventions should the nurse include in the client's plan of care?.

Correct Answer is A

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 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 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?

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?

Your patient is experiencing extrapyramidal symptoms (EPS) from antipsychotic therapy. You understand that the following medications are used to reverse EPS. (Select All that Apply.).

A nurse is caring for a client who has schizophrenia and is experiencing a variety of hallucinations. Which of the following hallucinations is the priority for the nurse to address?

A nurse is caring for a client who is experiencing suicidal thoughts. Which of the following actions should the nurse take?.