A nurse is conducting an admission interview with a new client who tells the nurse, "My life is so stressful.
I can't take it anymore.”. Which of the following responses should the nurse make first?

"Tell me what makes you feel stressed.”.

"How have you dealt with stress in the past?".

"Let's talk more about what you are experiencing.”.

"Are you thinking of harming yourself?". .

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Asking the client to describe what makes them feel stressed is important for understanding their situation, but it is not the immediate priority when there is concern about self-harm.

Choice B rationale:

Inquiring about the client's past coping mechanisms is relevant, but it should not be the first question when there is a potential risk of self-harm.

Choice C rationale:

Discussing what the client is experiencing is important, but it is not the primary concern when there is a risk of self-harm.

Choice D rationale:

Asking the client if they are thinking of harming themselves is the immediate priority in this situation. It helps assess the client's safety and the need for further intervention. Please let me know if you have more questions or need further explanations. .

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Correct Answer is C

Explanation

Choice A rationale:

The nurse should not offer advice about various treatment choices to the client who has just received a terminal cancer diagnosis. At this point, the client should be provided with information about available treatment options by the healthcare provider. The nurse's role is to offer support, empathy, and help facilitate communication between the client and the provider. Offering advice about treatment choices is beyond the scope of the nurse's role in this situation.

Choice B rationale:

Discouraging the client from forming new relationships is not appropriate. The client's emotional and psychosocial needs are important, and it's essential to encourage meaningful connections and relationships, especially in a difficult time like receiving a terminal diagnosis. Isolation can have negative effects on the client's emotional well-being, so the nurse should support the client in maintaining relationships.

Choice D rationale:

Changing the subject when the client becomes upset is not an appropriate action. It's important for the nurse to provide emotional support and a listening ear to the client during this challenging time. Changing the subject may come across as dismissive or uncaring, and it does not address the client's emotional needs.

A. Auditory hallucinations. B. Flight of ideas. C. Decreased motivation. D. Impaired memory.

Correct Answer is ["A","B"]

Explanation

Choice A rationale:

Auditory hallucinations are considered a positive symptom of schizophrenia. Positive symptoms are characterized by the presence of abnormal experiences or behaviors that are not typically present in individuals without schizophrenia. Auditory hallucinations involve hearing voices or sounds that are not real.

Choice B rationale:

Flight of ideas is a positive symptom of schizophrenia. It is characterized by a rapid and disorganized flow of thoughts, often leading to incoherent speech. This symptom is part of the formal thought disorder commonly seen in individuals with schizophrenia.

Choice C rationale:

Decreased motivation is not a positive symptom; it is considered a negative symptom of schizophrenia. Negative symptoms are characterized by a reduction or loss of normal functions or behaviors that are typically present in healthy individuals. Decreased motivation reflects a lack of interest, energy, or drive to engage in activities.

Choice D rationale:

Impaired memory is not a positive symptom but is more associated with cognitive deficits, which can be a part of schizophrenia, but it falls under cognitive symptoms rather than positive symptoms.

Choice E rationale:

Delusions of grandeur are positive symptoms of schizophrenia. Delusions are false beliefs that are firmly held despite evidence to the contrary. Delusions of grandeur involve a person having an exaggerated sense of self-importance or abilities. This is a classic positive symptom seen in schizophrenia. .

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A nurse is conducting an admission interview with a new client who tells the nurse, "My life is so stressful.I can't take it anymore.”. Which of the following responses should the nurse make first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has just received a terminal cancer diagnosis from his provider.Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse document as positive symptoms of schizophrenia? (Select all that apply.).

Correct Answer is ["A","B"]

Explanation

A nurse is caring for a client who exhibits chronic physical symptoms that cannot be fully explained by medical conditions.These symptoms cause distress and impairment in the client's daily life.What term is used to describe this condition?

A nurse is assessing a client who has delirium.Which of the following findings requires immediate intervention by the nurse?

A nurse is caring for a client who has borderline personality disorder.Which of the following actions should the nurse take?

A nurse is receiving change-of-shift report for four clients.Which of the following clients should the nurse see first?

A nurse is caring for a client who is undergoing electroconvulsive therapy. Which of the following tasks should the nurse delegate to an assistive personnel?

A nurse is caring for a client who has alcohol use disorder and is experiencing withdrawal. The nurse should monitor the client for which of the following manifestations?

A nurse is caring for a client who has Alzheimer's disease. Which of the following findings should the nurse expect?

A nurse in a long-term care facility is caring for a client.The nurse should identify that which of the following conditions places the client at an increased risk for developing delirium?

A nurse is conducting an admission interview with a new client who tells the nurse, "My life is so stressful.
I can't take it anymore.”. Which of the following responses should the nurse make first?