After being in the hospital for one month, a client with schizophrenia states that voices are telling them they will die tonight. The client asks the nurse if this is true. The client’s statement and question indicate that they:

Have a poor prognosis.

Are not improving and may be getting worse.

Are questioning the hallucination and want reassurance from the nurse.

Will begin to enter the manic phase of their illness.

Answer and Explanation

The Correct Answer is C

Choice A Reason: Have a poor prognosis

A poor prognosis in schizophrenia is typically associated with persistent and severe symptoms, lack of response to treatment, and significant functional impairment. While the client’s statement about hearing voices is concerning, it does not necessarily indicate a poor prognosis on its own. Prognosis in schizophrenia is multifactorial and depends on various factors, including the duration of untreated psychosis, adherence to treatment, and the presence of supportive social networks.

Choice B Reason: Are not improving and may be getting worse

This choice suggests that the client’s condition is deteriorating. While the presence of hallucinations can indicate a lack of improvement, it is important to consider the context. The client’s ability to question the hallucination and seek reassurance from the nurse suggests a level of insight that is often associated with better outcomes. Insight into one’s condition is a positive prognostic factor in schizophrenia.

Choice C Reason: Are questioning the hallucination and want reassurance from the nurse

This is the correct answer. The client’s question indicates that they are aware that the voices might not be real and are seeking reassurance from the nurse. This level of insight is crucial in managing schizophrenia, as it can lead to better adherence to treatment and improved outcomes. Insight into the nature of hallucinations and delusions is often a sign of a more favorable prognosis.

Choice D Reason: Will begin to enter the manic phase of their illness

Mania is characterized by elevated mood, increased activity, and other symptoms such as decreased need for sleep and grandiosity. It is more commonly associated with bipolar disorder than schizophrenia. The client’s statement about hearing voices predicting their death does not align with the typical presentation of mania. Therefore, this choice is not applicable in this context.

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Correct Answer is ["0.5"]

Explanation

Step 1: Identify the available concentration of fentanyl.

The ampule contains 100 micrograms of fentanyl in 2 mL.

Step 2: Determine the dose required.

The nurse needs to give 25 micrograms of fentanyl.

Step 3: Calculate the volume (mL) needed for the required dose.

Use the formula: (Dose required ÷ Dose available) × Volume of available dose.

Step 4: Substitute the values into the formula.

(25 micrograms ÷ 100 micrograms) × 2 mL

Step 5: Perform the division.

25 micrograms ÷ 100 micrograms = 0.25

Step 6: Perform the multiplication.

0.25 × 2 mL = 0.5 mL

Result: The nurse will give 0.5 mL for the correct dose.

Final Answer: 0.5 mL

A. Confirming boundaries by setting limits on behavior. B. Providing reality orientation. C. Providing client education in a direct manner. D. Ensuring physical need fulfillment.

Correct Answer is A

Explanation

Choice A Reason:

Confirming boundaries by setting limits on behavior.

This response is correct because it directly addresses the need to set clear boundaries with the client. In a psychiatric setting, it is crucial to establish and maintain professional boundaries to ensure a therapeutic environment. By limiting the client’s approach to the nurse’s station, the nurse is setting a clear boundary that helps manage the client’s behavior and ensures that the nurse can attend to other patients as well. This intervention helps in maintaining structure and predictability, which can be very beneficial for clients with psychiatric conditions.

Choice B Reason:

Providing reality orientation.

Providing reality orientation involves helping clients understand their surroundings and current situation, often used for clients with cognitive impairments or disorientation. While important, this intervention does not specifically address the behavior of frequently approaching the nurse’s station. Reality orientation would be more relevant in cases where the client is confused about time, place, or person.

Choice C Reason:

Providing client education in a direct manner.

Providing client education is essential, but it does not directly relate to setting behavioral limits. Education might involve explaining the reasons behind certain rules or treatments, but it does not address the immediate need to manage the client’s frequent requests. The intervention described in the question is more about behavior management than education.

Choice D Reason:

Ensuring physical need fulfillment.

Ensuring physical need fulfillment involves addressing the client’s basic needs such as food, hydration, and comfort. While this is a fundamental aspect of nursing care, it does not relate to setting behavioral limits or managing the frequency of the client’s requests. The intervention in the question is focused on managing behavior rather than fulfilling physical needs.

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After being in the hospital for one month, a client with schizophrenia states that voices are telling them they will die tonight. The client asks the nurse if this is true. The client’s statement and question indicate that they:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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.

Correct Answer is ["0.5"]

Explanation

A client on an acute psychiatric inpatient unit approaches the nurse’s station every 10-15 minutes with various requests. The nurse intervenes by stating, “You may approach the nurse’s station only once an hour.” Which nursing intervention has been employed?

Correct Answer is A

Explanation

A client with a diagnosis of schizophrenia says to the student nurse, “The mazurkas are coming. The mazurkas are coming.” The client’s use of the word ‘mazurka’ is most likely a/an:

Which action should the nurse take prior to educating clients about relaxation techniques?

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 diagnosed with generalized anxiety disorder (GAD) is started on buspirone. Which statement made by the client indicates teaching has been effective? The client verbalizes that:

The nurse must prepare an oral contrast solution in 850 mL of apple juice. There are 6-ounce containers of apple juice in the pantry. What is the minimum number of containers of juice to make 850 mL? (Round the answer to the nearest whole container)

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:

A client diagnosed with Obsessive-Compulsive Disorder has developed a number of compulsive washing rituals over the years. The nurse recognizes that these behavioral rituals serve which purpose?