On review of the client’s record, the nurse notes that the admission was voluntary. Based on this information, the nurse plans care anticipating which client behavior?

Anger and aggressiveness directed toward others

Fearfulness regarding treatment measures

Willingness to participate in the planning of the care and treatment plan

An understanding of the pathology and symptoms of the diagnosis

Answer and Explanation

The Correct Answer is C

Choice A reason:
Anger and aggressiveness directed toward others are not typically associated with voluntary admission. Clients who voluntarily seek treatment are usually motivated to improve their condition and are less likely to exhibit aggressive behaviors towards others. Aggressiveness may be more common in involuntary admissions where the client feels coerced.

Choice B reason:
Fearfulness regarding treatment measures can occur in any client, regardless of whether the admission is voluntary or involuntary. However, clients who voluntarily admit themselves are generally more open to treatment and less likely to exhibit significant fearfulness about the treatment process.

Choice C reason:
Willingness to participate in the planning of the care and treatment plan is a common behavior in clients who have voluntarily admitted themselves. These clients are typically motivated to engage in their treatment and collaborate with healthcare providers to achieve their health goals. Voluntary admission often indicates a proactive approach to managing their condition.

Choice D reason:
An understanding of the pathology and symptoms of the diagnosis is not necessarily linked to the nature of the admission. While some clients may have a good understanding of their condition, others may not, regardless of whether their admission was voluntary or involuntary. Education about the diagnosis is an important part of the treatment process for all clients.

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Correct Answer is D

Explanation

Choice A reason:
An illusion is a misinterpretation of a real external stimulus. For example, seeing a shadow and thinking it is a person. The client’s statement does not indicate a misinterpretation of reality but rather a desire to inflict harm on themselves.
Choice B reason:
A hallucination is a false sensory perception without any real external stimulus, such as hearing voices or seeing things that are not there. The client’s statement does not suggest they are experiencing a hallucination but rather expressing a desire to self-harm.
Choice C reason:
Attention-seeking behavior involves actions taken to gain attention from others. While the client’s statement could be seen as a cry for help, it is more accurately identified as a risk for self-mutilation due to the explicit mention of wanting to cut themselves.
Choice D reason:
Self-mutilation refers to deliberate self-inflicted harm, often as a way to cope with emotional pain. The client’s statement, “Give me your pen to cut the pain out of my chest,” clearly indicates a risk for self-mutilation, as they are expressing a desire to harm themselves to alleviate emotional distress.

A. Fasting blood glucose 120mg/dL B. Hypertension C. Asthma D. WBC count 3,300/mm³

Correct Answer is D

Explanation

Choice A reason:
Fasting blood glucose of 120 mg/dL is slightly elevated but does not contraindicate the use of chlorpromazine. This medication is primarily contraindicated in conditions that affect the central nervous system, cardiovascular system, or blood cell counts. Elevated blood glucose levels should be monitored, but they do not pose an immediate risk when starting chlorpromazine.

Choice B reason:
Hypertension is a condition that requires careful monitoring when a patient is on chlorpromazine, but it is not an absolute contraindication. Chlorpromazine can cause orthostatic hypotension, so blood pressure should be monitored regularly. However, hypertension alone does not prevent the use of this medication.

Choice C reason:
Asthma is not a contraindication for chlorpromazine. While respiratory conditions should be monitored, chlorpromazine does not have a direct adverse effect on asthma. The primary concerns with chlorpromazine involve its effects on the central nervous system and blood cell counts.

Choice D reason:
A WBC count of 3,300/mm³ indicates leukopenia, which is a significant contraindication for chlorpromazine. This medication can cause agranulocytosis, a severe reduction in white blood cells, making patients more susceptible to infections. Therefore, a low WBC count is a critical factor in deciding against the use of chlorpromazine.

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On review of the client’s record, the nurse notes that the admission was voluntary. Based on this information, the nurse plans care anticipating which client behavior?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has bipolar disorder. The client says to the nurse, “Give me your pen to cut the pain out of my chest.” The nurse should identify that the client is at risk for which of the following?

Correct Answer is D

Explanation

A nurse is reviewing the medical record of a client who has a new prescription for chlorpromazine for the treatment of schizophrenia. Which of the following findings indicates a contraindication to chlorpromazine?

Correct Answer is D

Explanation

A nurse is providing in-home mental health care and determines that the care is effective when the client demonstrates which response?

A nurse is preparing to discharge a client who has been diagnosed with schizophrenia. The client asks, “I am not sure why I need to have a relapse plan.” Which of the following responses should the nurse make?

When providing care to a client diagnosed with a mental disorder, the client asks the nurse, “Does mental illness run in your family?” Which response by the nurse would be nontherapeutic?

A nurse is interviewing a client who is experiencing negative symptoms of psychosis about their family history of schizophrenia. In which of the following phases of the nursing process should this take place?

A nurse is developing a plan of care integrating Maslow’s hierarchy of needs. Which area would the nurse identify as the priority?

When applying the biopsychosocial model to a client with a mental health problem, the nurse addresses which psychological domain?