The nurse is assessing a client with paranoia. Which behavior can this client be expected to exhibit?

Tries to run the unit, telling everyone what to do and when to do it.

Is openly hostile to others for no apparent reason.

Repeatedly tries to commit suicide.

Talks to voices only the client can hear.

Answer and Explanation

The Correct Answer is B

Choice A reason: Controlling the unit reflects grandiosity or mania, not paranoia. Paranoid clients are more likely to exhibit hostility due to perceived threats. This behavior is less typical of paranoia’s suspicious nature, making it incorrect for expected behavior in a paranoid client.

Choice B reason: Open hostility for no apparent reason is common in paranoia, as clients misinterpret others’ actions as threatening due to delusional beliefs. This aligns with psychiatric descriptions of paranoid behavior, making it the most expected behavior for a client with paranoia during assessment.

Choice C reason: Repeated suicide attempts are associated with depression or borderline personality disorder, not primarily paranoia. Hostility from perceived threats is more characteristic of paranoia, making suicide attempts less expected and incorrect for the typical behavior in this client.

Choice D reason: Talking to voices suggests hallucinations, more common in schizophrenia with auditory hallucinations than in paranoia alone. Hostility from suspicion is a more direct paranoid behavior, making this incorrect, as hallucinations are not the primary expected feature of paranoia.

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Correct Answer is C

Explanation

Choice A reason: Progressive exposure to crowds is part of desensitization but is not the highest priority initially. Without trust and a safe environment, exposure may overwhelm the client, hindering therapy. Establishing trust ensures the client feels secure to engage in desensitization, making this less immediate than building rapport.

Choice B reason: Substituting positive thoughts helps manage anxiety but is secondary to establishing trust. Without a safe, trusting environment, cognitive strategies may be ineffective for a client with agoraphobia. Trust facilitates engagement in therapy, making this intervention less critical than creating a calm, supportive setting initially.

Choice C reason: Establishing trust by providing a calm, safe environment is the highest priority, as it builds the foundation for desensitization therapy. For agoraphobia, feeling secure enables the client to engage in exposure and cope with anxiety, aligning with psychiatric nursing principles for anxiety disorder management.

Choice D reason: Deep breathing is a useful coping strategy for anxiety but is less critical than establishing trust. Without a safe environment, the client may not feel secure enough to practice techniques during crowd exposure. Trust is foundational for therapeutic success, making this intervention secondary.

A. Decreased bowel movements. B. Decreasing hand tremors. C. Increased mouth movements. D. Presence of a dry mouth.

Correct Answer is C

Explanation

Choice A reason: Decreased bowel movements (constipation) are a common side effect of benztropine due to its anticholinergic properties, but they do not indicate worsening EPS or treatment failure. Increased mouth movements suggest persistent or worsening EPS, requiring further evaluation, making constipation less critical for immediate reassessment.

Choice B reason: Decreasing hand tremors indicate benztropine’s effectiveness in treating EPS, as it reduces parkinsonian symptoms like tremors. This is a desired outcome, not a cause for further evaluation. Increased mouth movements, suggesting tardive dyskinesia or EPS persistence, are more concerning, making this incorrect.

Choice C reason: Increased mouth movements, such as tardive dyskinesia or dystonia, suggest worsening or inadequately controlled EPS, potentially indicating benztropine’s ineffectiveness or a need for dose adjustment. This finding warrants further evaluation, aligning with psychopharmacology evidence for monitoring anticholinergic therapy, making it the correct choice.

Choice D reason: Dry mouth is a common anticholinergic side effect of benztropine, not an indicator of EPS worsening. It is expected and manageable, unlike increased mouth movements, which signal potential EPS complications. This finding does not require immediate evaluation, making it incorrect for further nursing assessment.

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The nurse is assessing a client with paranoia. Which behavior can this client be expected to exhibit?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who has agoraphobia (a fear of crowds) is beginning desensitization with the therapist, and the nurse is reinforcing the process. Which intervention has the highest priority for this client's plan of care?

Correct Answer is C

Explanation

A client is receiving benztropine mesylate for drug-induced extrapyramidal syndrome (EPS). Which finding indicates that the nurse should further evaluate the client?

Correct Answer is C

Explanation

A client with bipolar disorder tells the nurse about the need to make some deals to improve a retirement savings. Based on this information, which client outcome should the nurse include in the care?

The mother of an 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?

The nurse is assessing a client who reports using cocaine several times in the past week. Which observations should the nurse document?

A client at the mental health center reports difficulty concentrating at work, feeling very tired during the day, and sleeping 4 to 5 hours at night. To further assess for depression, which question is most important for the nurse to ask?

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?

A nurse who is co-leading group therapy recognizes that a client is beginning to experience severe levels of anxiety. Which intervention is best for the nurse to implement?