The nurse documents that a male client with schizophrenia is delusional. Which statement by the client confirms this assessment?

"The snakes on the wall are going to eat me."

"The voices are telling me to kill the next person I see."

"The nurse at night is trying to poison me with pills.

"The fire is burning my skin away right now."

Answer and Explanation

The Correct Answer is C

A. "The snakes on the wall are going to eat me" indicates a hallucination, specifically a visual hallucination. Hallucinations involve perceiving something that is not present, such as seeing or hearing things that others do not. This statement does not confirm delusions.

B. Hearing voices instructing harm doesn't confirm delusions but auditory hallucinations.

C. "The nurse at night is trying to poison me with pills" reflects a delusion, specifically a persecutory delusion. Delusions are false, fixed beliefs that are not based in reality and are resistant to reasoning or contradictory evidence. This statement indicates a belief that someone is attempting harm, which is characteristic of delusional thinking.

D. Believing fire is burning the skin could suggest a hallucination involving sensations, not necessarily a delusion.

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Correct Answer is B

Explanation

A. Familial history of mental illness is important but might not directly impact the initiation of sertraline treatment.
B. Medication history is the most important information to obtain before starting sertraline. This includes any current medications the client is taking, especially other antidepressants, anticoagulants, or medications that may interact with sertraline. Sertraline is a selective serotonin reuptake inhibitor (SSRI), and it can interact with other medications, such as monoamine oxidase inhibitors (MAOIs) or other serotonergic drugs, leading to serious side effects like serotonin syndrome.

C. While current weight may be important for monitoring side effects such as weight gain, it is not as immediately critical as understanding the client’s medication history, particularly regarding potential drug interactions.

D. A history of heart disease is relevant to the overall health assessment, but sertraline is generally considered safe for most individuals with heart disease. However, the medication history is more crucial because of potential drug interactions.

A. Haloperidol B. Folic Acid. C. Trazodone D. Vitamin B1.

Correct Answer is D

Explanation

A. Haloperidol might be used in some detoxification scenarios but isn't directly indicated based on the information provided.
B. Folic acid is not an immediate medication administered during alcohol detoxification.
C. Trazodone is used for other purposes and is not an immediate medication in alcohol detoxification.
D. Vitamin B1 (thiamine) supplementation is crucial during alcohol detoxification to prevent Wernicke-Korsakoff syndrome or other neurological complications associated with
alcohol withdrawal.

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The nurse documents that a male client with schizophrenia is delusional. Which statement by the client confirms this assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Prior to initiating a treatment regimen with the antidepressant sertraline, it is most important for the nurse to obtain which information?

Correct Answer is B

Explanation

A client with a history of alcoholism is admitted for detoxification. Based on treatment protocol, the nurse gives the client a dose of lorazepam 6 mg. Which additional prescription should the nurse administer immediately?

Correct Answer is D

Explanation

The nurse is planning the care for a client who is hospitalized with bipolar disorder. The client wanders the hallways, talks excessively, and makes sexual comments about the staff. Which intervention(s) should the nurse include in the plan of care? (Select all that apply.)

Following the visit, what are appropriate actions for the nurse? Select all that apply.

A client with schizophrenia is demonstrating echolalia, which is becoming annoying to other clients on the unit. Which intervention is best for the nurse to implement?

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A client with post-traumatic stress disorder (PTSD) is admitted to the psychiatric unit. Which intervention is most important for the nurse to include in this client's plan of care?

The mother of an 8-month-old infant with profound mental and physical disabilities tells the nurse how depressed she is because she realizes that her child will never achieve normal growth and development milestones. How should the nurse respond to this mother?

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