The nurse is observing the interaction between a mother and schizophrenic son. The son states, "The man visiting me said you went on vacation without me." The mother replied, "There is no man, you are just making that up." When interacting with the mother privately, which reply from the mother would the nurse suggest?

"I am not on vacation. I am here with you."

"How can I go on vacation. I do not have any money."

"Stop saying that. You know better. No one told you that."

"Just forget about that and let's talk about something else."

Answer and Explanation

The Correct Answer is A

A. "I am not on vacation. I am here with you." This response calmly reassures the client by affirming the mother’s presence, which helps address the son’s confusion without directly challenging his perception.

B. "How can I go on vacation? I do not have any money." This response could increase confusion and does not address the son's needs effectively. It could also lead to unnecessary discussions that might not be helpful.

C. "Stop saying that. You know better. No one told you that." This response is dismissive and confrontational, which may exacerbate the son’s distress and could damage the therapeutic relationship.

D. "Just forget about that and let's talk about something else." This response avoids addressing the son’s concerns, which can make him feel dismissed and not listened to, potentially worsening his symptoms.

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Correct Answer is B

Explanation

A. Generalized anxiety disorder: Generalized anxiety disorder involves persistent and excessive worry, but it does not typically present with the specific symptoms of nightmares and flashbacks related to trauma.

B. Posttraumatic stress disorder: PTSD is characterized by symptoms such as nightmares, flashbacks, and difficulty sleeping, especially following exposure to traumatic events. This fits the soldier’s presentation.

C. Obsessive-compulsive disorder: OCD involves recurrent, intrusive thoughts (obsessions) and/or repetitive behaviors (compulsions). The symptoms described do not align with OCD but rather with trauma-related symptoms.

D. Social phobia: Social phobia involves intense fear of social situations, not the trauma-related symptoms described. It is less relevant to the soldier’s experience of nightmares and flashbacks.

A. Leave the client alone during a new experience. B. Give support in nonverbal ways. C. Be available and attentive to the client's requirements. D. Give detailed explanations and do not repeat them frequently.

Correct Answer is C

Explanation

A. Leave the client alone during a new experience. Leaving an anxious client alone during a new experience may increase their anxiety and hinder the development of trust. Clients need support and reassurance during unfamiliar situations.

B. Give support in nonverbal ways. Nonverbal support, such as a calm presence or gentle touch, can be comforting and help build trust without overwhelming the client with too much verbal communication.

C. Be available and attentive to the client's requirements. Being available and attentive shows the client that the nurse is reliable and responsive to their needs, which helps build trust in the therapeutic relationship.

D. Give detailed explanations and do not repeat them frequently. While providing detailed explanations is important, failing to repeat them as needed could leave the client feeling unsupported or confused, especially if they need reassurance.

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Naxlex Comprehensive Predictor Exams

A soldier has been back from Iraq for two weeks. He is being seen in the outpatient mental health clinic due to complaints of inability to sleep, nightmares, and flashbacks. The nurse would expect the client to be diagnosed with which of the following?

Correct Answer is B

Explanation

Building trust is especially critical to developing a therapeutic relationship with an anxious client. Which of the following interventions contributes to this trust?

Correct Answer is C

Explanation

A client who suffers from bipolar disorder is admitted to a mental health unit for a manic episode. The nurse knows that which takes priority?

Which of the following assessment findings is observed in a client with opiate use?

Which of the following nursing interventions should a nurse perform when caring for a female client with mood disorder who is prescribed lithium?

A nurse is performing a neurologic assessment on a client with a stroke and cannot elicit a gag reflex. This deficit is related to cranial nerve (CN) X, the vagus nerve. What will the nurse consider a priority nursing diagnosis?

The nurse is caring for a client who is being treated in the emergency department for a panic attack. Which of the following nursing interventions would be most appropriate?

A nurse is caring for a client with complaints of xerostomia. The nurse should encourage the client to:

During the interview of a client, the client states, "I have trouble falling asleep." Which action would be appropriate for a nurse to do next?

A psychiatric mental-health nurse is evaluating the treatment plan of an adult client diagnosed with schizophrenia disorder with aggressive behaviors. Which outcome of the client would demonstrate successful treatment?