For the nurse managing the therapeutic milieu, the most heavily weighted factor in determining whether a client should receive a prn dose of Haloperidol is whether

less-restrictive alternatives have been tried without success

the medication will make the work of the staff easier or safer

the client is willing to accept the medication

the clients behavior indicates possible danger to self, others or the environment

Answer and Explanation

The Correct Answer is D

A. Less-restrictive alternatives have been tried without success: While it is important to explore less-restrictive alternatives before resorting to medication, the immediate concern is the client's safety and the safety of others. If the client's behavior poses a significant risk, prompt intervention may be necessary.

B. The medication will make the work of the staff easier or safer: While staff safety is important, the primary consideration for administering a prn dose of Haloperidol is the clinical need based on the client's behavior and potential danger to themselves, others, or the environment.

C. The client is willing to accept the medication: Client willingness to accept medication is relevant for promoting collaboration in treatment, but the urgency in administering a prn dose is often based on the client's behavior and the level of risk they pose.

D. The client's behavior indicates possible danger to self, others, or the environment: This is the most critical factor in determining the need for a prn dose. If a client's behavior poses a significant risk, such as aggression, violence, or extreme agitation, administering a prn dose of medication may be necessary to ensure safety and prevent harm.

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Correct Answer is C

Explanation

A. Concrete thinking: Concrete thinking refers to a style of thinking that is focused on immediate and literal aspects of information. The patient's statement involves more than concrete thinking; it includes an irrational belief about the consequences of contagious bacteria, indicating a distorted perception of reality.

B. Agitation: Agitation refers to a state of restlessness or increased activity. The patient's statement does not necessarily reflect agitation but rather a specific paranoid belief about the consequences of bacteria exposure.

C. Paranoia: This is the correct answer. Paranoia involves irrational thoughts and fears of being harmed or persecuted by others. The patient's belief that contagious bacteria are everywhere and will lead to being locked up with other infected people is indicative of paranoid ideation.

D. Poverty of thought: Poverty of thought is characterized by a lack of meaningful or detailed thought content. The patient's statement is not an example of poverty of thought; rather, it involves specific and elaborate content related to a paranoid belief.

A. Did you take your medicine this morning? B. i'm sure the voices sound scary, I don't hear any voices speaking C. The devil only talks to people who are receptive to his influence D. You are not going to hell. You are a good person

Correct Answer is B

Explanation

A. "Did you take your medicine this morning?": While medication adherence is important, this response does not directly address the client's distress or validate their experience. It may come across as dismissive.

B. "I'm sure the voices sound scary, I don't hear any voices speaking.": This response acknowledges the client's experience without confirming or denying the presence of the voices. It expresses empathy and provides reassurance, fostering a therapeutic relationship.

C. "The devil only talks to people who are receptive to his influence": This response introduces a belief system that may not align with the client's reality and could be perceived as judgmental. It's important to avoid imposing personal beliefs on clients experiencing hallucinations.

D. "You are not going to hell. You are a good person": While expressing support and reassurance is positive, making definitive statements about the client's fate or goodness may not be helpful. It's more effective to acknowledge the distress without making absolute affirmations.

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For the nurse managing the therapeutic milieu, the most heavily weighted factor in determining whether a client should receive a prn dose of Haloperidol is whether

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient diagnosed with schizophrenia says, "Contagious bacteria are everywhere. When they get in your body, you will be locked up with other Infected people. Which problem is evident?

Correct Answer is C

Explanation

A client diagnosed with schizophrenia states, Can't you hear him? Its the devil. He's telling me I'm going to hell. Which is the most appropriate nursing reply?

Correct Answer is B

Explanation

A new nurse is reviewing the various types of groups available on her new unit. One group adds new members as others leave. She recognizes this type of group as a(n) group?

A client diagnosed with brief psychotic disorder tells a nurse about voices telling him to kill the president. Which nursing diagnosis should the nurse prioritize for this client?

The patient admitted with antisocial disorder will display which symptom(s)?

What is the purpose of a nurse gathering client information?

A client on an inpatient unit angrily says to a nurse. "Peter is not cleaning up after himself in the community bathroom. You need to address this problem. Which is the appropriate nursing response?

A cab driver stuck in traffic is suddenly lightheaded, tremulous, and diaphoretic and experiences tachycardia and dyspnea. An extensive workup in an emergency department reveals no pathology. Which medical diagnosis is suspected, and what nursing diagnosis takes priority?

A 16-year-old client diagnosed with schizophrenia experiences command hallucinations to harm others. The clients parents ask a nurse. Where do the voices come from? Which is the appropriate nursing reply?

A nurse is teaching about sources of psychological stress to a group of newly licensed nurses. The nurse should identify which of the following qualifies as a source of psychological distress?