A nurse notices that a client with paranoid schizophrenia stops in mid-sentence when talking and tilts his head to the side as if to listen. The most appropriate intervention by the nurse would be to:

Ask the client, “What are the voices saying to you?”

Give the client a PRN dose of benztropine.

Call and report the behavior to the physician.

Tell the client, “Well, I see you’re distracted right now. We’ll talk more later.”

Answer and Explanation

The Correct Answer is A

The correct answer is a.

Choice A Reason:

The statement “Ask the client, ‘What are the voices saying to you?’” is correct. Engaging the client in a conversation about their hallucinations can help the nurse understand the content and nature of the hallucinations, which is crucial for assessing the client’s risk of harm to themselves or others. This approach also validates the client’s experience and can help build trust and rapport. It is important to approach the client with empathy and without judgment, as this can help in managing the symptoms more effectively.

Choice B Reason:

The statement “Give the client a PRN dose of benztropine” is incorrect. Benztropine is an anticholinergic medication used to treat extrapyramidal symptoms caused by antipsychotic medications. It is not used to manage auditory hallucinations directly. Administering benztropine without a clear indication could lead to unnecessary side effects and does not address the immediate issue of the hallucinations.

Choice C Reason:

The statement “Call and report the behavior to the physician” is incorrect. While it is important to keep the physician informed about significant changes in the client’s condition, the immediate intervention should focus on addressing the client’s current experience. Reporting the behavior without first attempting to understand and manage the hallucinations may delay appropriate care and support for the client.

Choice D Reason:

The statement “Tell the client, ‘Well, I see you’re distracted right now. We’ll talk more later.’” is incorrect. This response dismisses the client’s current experience and may make them feel misunderstood or ignored. It is important to address the client’s immediate needs and provide support rather than postponing the conversation. Acknowledging the client’s experience and offering to discuss it can help in managing the symptoms and providing appropriate care.

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Correct Answer is ["A","C","D"]

Explanation

Choice A Reason:

The statement “Documentation of the event will include interventions attempted prior to initiating restraints” is correct. Proper documentation is crucial when restraints are used. This includes detailing the client’s behavior that necessitated the restraint, the interventions attempted before applying the restraint, the type of restraint used, and the time it was applied. This documentation ensures transparency and accountability, and it helps in evaluating the necessity and appropriateness of the restraint use.

Choice B Reason:

The statement “The physician must be present at the time of the restraint episode” is incorrect. While a physician’s order is required for the use of restraints, the physician does not need to be physically present at the time of the restraint episode. However, the physician must evaluate the client within a specified time frame after the restraint is applied, typically within one hour. This ensures that the restraint is medically justified and that the client’s condition is appropriately monitored.

Choice C Reason:

The statement “The client will be turned every 2 hours” is correct. Clients in restraints must be regularly repositioned to prevent complications such as pressure ulcers and to ensure their comfort. Turning the client every 2 hours is a standard practice to maintain skin integrity and promote circulation. This intervention is part of the comprehensive care plan for clients in restraints.

Choice D Reason:

The statement “The client will need to be monitored every one-half hour” is correct. Frequent monitoring of clients in restraints is essential to ensure their safety and well-being. This includes checking for signs of distress, ensuring that the restraints are not causing harm, and assessing the client’s vital signs5. Monitoring every 30 minutes helps in promptly addressing any issues that may arise and ensures that the restraints are used safely and effectively.

A. The client is always aware that their behaviors are maladaptive. B. The client uses adaptive defense mechanisms to cope. C. The client never has mood or personality changes. D. The client does not experience loss of contact with reality.

Correct Answer is D

Explanation

Choice A Reason:

The statement “The client is always aware that their behaviors are maladaptive” is incorrect. While individuals with neurotic behavior may sometimes recognize that their behaviors are maladaptive, this awareness is not consistent. Neurotic behaviors are often automatic and unconscious efforts to manage deep anxiety. Therefore, the client may not always be aware of the maladaptive nature of their actions.

Choice B Reason:

The statement “The client uses adaptive defense mechanisms to cope” is incorrect. Neurotic behavior typically involves the use of maladaptive defense mechanisms rather than adaptive ones. These mechanisms, such as denial, repression, or projection, are employed to manage anxiety and stress but do not effectively resolve the underlying issues. Adaptive defense mechanisms, on the other hand, are more constructive and promote healthier coping strategies.

Choice C Reason:

The statement “The client never has mood or personality changes” is incorrect. Neurotic behavior is often associated with mood swings and emotional instability. Clients with neurotic tendencies may experience frequent changes in mood and may struggle with regulating their emotions. Therefore, it is inaccurate to state that the client never has mood or personality changes.

Choice D Reason:

The statement “The client does not experience loss of contact with reality” is correct. Neurotic behavior, unlike psychotic behavior, does not involve a loss of contact with reality4. Clients with neurotic tendencies remain aware of their surroundings and can distinguish between reality and their internal experiences4. This characteristic differentiates neurotic behavior from more severe mental health conditions such as schizophrenia, where a loss of reality is a key feature.

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A nurse notices that a client with paranoid schizophrenia stops in mid-sentence when talking and tilts his head to the side as if to listen. The most appropriate intervention by the nurse would be to:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When placing an agitated client in restraints, the nurse understands that which of the following must occur?

Correct Answer is ["A","C","D"]

Explanation

A nurse working on a psychiatric unit is providing care for a client that reports feeling irritable and distressed. The client states, “I just feel so helpless.” Which of the following statements most aligns with the client’s presentation of neurotic behavior?

Correct Answer is D

Explanation

The nurse who has been caring for a client with generalized anxiety disorder (GAD) recognizes that care has been effective when the client is able to: (SELECT ALL THAT APPLY)

The nurse must give 25 micrograms of fentanyl IVP X1 dose. Fentanyl is available in an ampule 100 micrograms per 2m How many mL will the nurse give for the correct dose? round to the nearest tenth. Use a preceding zero if necessary. Do not use trailing zeros.

Group therapy is strongly encouraged, but not mandatory, in an inpatient psychiatric unit. The unit manager’s policy is that clients can make a choice about whether or not to attend group therapy. Which ethical principle does the unit manager’s policy preserve?

A client with schizophrenia approaches the nurse with a look of distress and anguish on his face. He says, “Can’t you hear him? It’s the devil. He’s telling me I’m going to hell.” Which is the most appropriate response by the nurse?

A young client asks the nurse for their telephone number, with the intent of calling to schedule a date. Which of the following responses would be most appropriate?

A client with schizophrenia has had 2 hospitalizations within the past 9 months due to non-adherence to medications and their counseling plan. What measures should the nurse and the mental health treatment team recommend for tertiary prevention? (Select All That Apply)

A client is admitted to the inpatient psychiatric unit with a diagnosis of a somatoform disorder. Which statement does the nurse recognize as true about all somatoform disorders?

The nurse is caring for a client with schizophrenia. Which of the following would be a priority nursing goal for this client’s care?