An adult male who is admitted to the mental health clinic is alert and oriented to person, place, time, and situation. His affect is blunted, his mood dysphoric, and the nurse identifies his responses as tangential with a paranoid theme when he states, “I have a chip inside my head that is speaking to me.” Based on these assessment findings, which nursing problem is best to include in this client’s initial plan of care?

Disturbed thought process related to paranoid ideation.

Disturbed sensory perception related to grandiose self-beliefs.

Impaired verbal communications related to psychosis.

Impaired social interaction related to unrealistic thought processes.

Answer and Explanation

The Correct Answer is A

Choice A reason: The client’s belief in a chip in his head indicates paranoid ideation, a disturbed thought process in schizophrenia, driven by dopamine dysregulation in the mesolimbic pathway. This nursing problem targets altered reality perception, guiding antipsychotic therapy to reduce delusions, addressing the core cognitive disturbance observed.

Choice B reason: Disturbed sensory perception implies hallucinations, not delusions. The chip belief is a paranoid delusion, not a sensory issue or grandiose belief. Schizophrenia involves cognitive distortions, and “disturbed thought process” better addresses the paranoid ideation, focusing on the neurobiological basis of delusional thinking over sensory misperceptions.

Choice C reason: Impaired verbal communication is inaccurate, as the client is alert and oriented with coherent, though tangential, speech. The chip delusion reflects a thought disorder, not communication deficit. Schizophrenia’s cognitive symptoms prioritize addressing thought processes, driven by neurotransmitter imbalances, over verbal expression issues.

Choice D reason: Impaired social interaction may result from paranoid delusions but is secondary. The primary issue is the disturbed thought process causing the chip delusion, rooted in dopamine dysregulation. Addressing the delusion directly with antipsychotics is more specific, as social issues stem from this core cognitive disturbance.

Nursing Test Bank

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Correct Answer is B

Explanation

Choice A reason: Exercise lowers blood glucose in type 2 diabetes by enhancing insulin sensitivity and glucose uptake via GLUT4 transporters in muscles. This statement is incorrect, as physical activity is vital for glycemic control, reducing hyperglycemia and cardiovascular risks. Proper understanding involves recognizing exercise’s role in metabolic management, not denying its impact.

Choice B reason: Following a tailored meal plan and avoiding high-fat diets is correct, as it regulates blood glucose and lipids in type 2 diabetes. Balanced carbohydrates and low saturated fats prevent insulin resistance and atherosclerosis. This reflects understanding of dietary management’s role in glycemic control, reducing complications like neuropathy or cardiovascular disease.

Choice C reason: Soaking feet in hot water is dangerous in diabetes due to neuropathy, which reduces sensation and increases burn risk. Hot water also dries skin, raising infection risk. Proper foot care involves daily inspection and avoiding extreme temperatures, making this statement incorrect and harmful for effective diabetes management.

Choice D reason: Covering wounds with antibiotic ointment without medical evaluation is risky, as diabetes impairs wound healing due to hyperglycemia and immune dysfunction. Proper care involves cleaning, monitoring, and consulting providers to prevent infections. This statement shows incomplete understanding, as it overlooks the need for professional wound management.

A. Ensure supplemental oxygen and respiratory medications are available at all times. B. Use nasal or cough tissues followed by handwashing at all times. C. Avoid large crowded areas during the colder months of the year. D. Get annual flu and Pneumococcal vaccine polyvalent (PPSV23) vaccines.

Correct Answer is D

Explanation

Choice A reason: Ensuring oxygen and medications manages exacerbations in asthma, bronchitis, and emphysema, where airway inflammation obstructs breathing. These treat symptoms, not prevent infections. Vaccines reduce influenza and pneumococcus, major exacerbation triggers, providing specific immunity to prevent severe respiratory infections, making them a higher priority.

Choice B reason: Using tissues and handwashing reduces infection spread but is less effective than vaccines for preventing exacerbations in chronic lung diseases. Influenza and pneumococcus trigger severe bronchoconstriction or inflammation. Vaccines offer targeted protection against these pathogens, prioritizing prevention over general hygiene in high-risk clients.

Choice C reason: Avoiding crowded areas in colder months reduces viral exposure, which can exacerbate asthma or COPD via inflammation. Vaccines are more effective, providing specific immunity against influenza and pneumococcus, the most common triggers of severe exacerbations, making this less critical than vaccination for preventing respiratory complications.

Choice D reason: Annual flu and PPSV23 vaccines are critical for asthma, bronchitis, and emphysema, as these conditions increase severe infection risk. Influenza and pneumococcus trigger exacerbations via airway inflammation, risking hospitalization. Vaccines stimulate antibody production, reducing infection severity, making them the top preventive measure for chronic lung disease management.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing teaching to a client with type 2 diabetes mellitus about important points for disease and symptom management. Which statement by the client indicates understanding?

Correct Answer is B

Explanation

The nurse is reviewing the recommended preventative care for clients with asthma, chronic bronchitis, and emphysema. Which health care measure is most important for the nurse to recommend to these clients?

Correct Answer is D

Explanation

In assessing tactile fremitus in the client with suspected pneumonia, the nurse should perform which action?

After placing a client who is having a seizure in the side-lying position, which intervention should the nurse implement?

The nurse is teaching a client with newly diagnosed glaucoma about the condition. Which statement by the client indicates a need for further teaching?

After a client voids, 150 mL of residual urine is measured. Which nursing problem should be included in this client’s plan of care?

A client with chronic kidney disease (CKD) is prescribed a low-potassium diet. Which food choice indicates to the nurse that the client understands the dietary restrictions?

An older male client reports nocturia with difficulty starting his urine stream. Which additional assessment should the nurse perform to obtain further data related to this information?

After suctioning a client who has an endotracheal tube, which assessment finding indicates to the nurse that the intervention was effective?