The nurse is teaching a client with paranoid personality disorder to validate ideas with another person before taking action. Which statement made by the client indicates that the teaching is effective?

"I will start basing my decisions and actions on reality."

"I am going to have to learn to trust other people."

"I will be able to differentiate when my suspicions are true."

"I understand the origins of my paranoid thinking."

Answer and Explanation

The Correct Answer is A

Choice A reason: This statement reflects an understanding of the need to ground perceptions in reality, which is a key step in managing paranoid personality disorder.

Choice B reason: While learning to trust others is important, it does not directly indicate that the client has learned to validate their ideas before acting.

Choice C reason: Being able to differentiate true suspicions can be part of managing the disorder, but it does not demonstrate an understanding of the need to validate ideas with others.

Choice D reason: Understanding the origins of paranoid thinking is insightful, but it does not show that the client has learned to validate their ideas before taking action.

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Correct Answer is ["A","C","D","E"]

Explanation

Choice A Reason:

Checking the client's pupil reactivity is important because alcohol intoxication can affect the nervous system, which may be reflected in changes in pupil size and reactivity to light. Normal pupil size ranges from about 2 to 4 mm in diameter in bright light to 4 to 8 mm in the dark. Pupils that do not respond to light could indicate a neurological deficit that requires immediate attention.

Choice B Reason:

Performing a developmental screening test is not typically indicated for acute alcohol intoxication management. Developmental screenings are generally used to assess children for appropriate growth and developmental milestones, not for adults in an emergency setting due to intoxication.

Choice C Reason:

Preparing the client for a CT scan may be necessary if there is a suspicion of head trauma or intracranial bleeding, which can occur with falls or injuries associated with intoxication. A CT scan can help identify any urgent issues that need to be addressed.

Choice D Reason:

Obtaining a urine specimen can be useful for several reasons. It can be tested for the presence of alcohol, other substances, or toxins. Additionally, it can provide information about the client's overall health and kidney function.

Choice E Reason:

Monitoring the client’s vital signs frequently is crucial. Alcohol intoxication can lead to vital sign abnormalities such as hypotension, tachycardia, or respiratory depression. Normal ranges for vital signs vary but generally include a blood pressure of 90/60 mmHg to 120/80 mmHg, a heart rate of 60 to 100 beats per minute, and a respiratory rate of 12 to 20 breaths per minute.

A. The client focuses conversations on nutritious food. B. The client gains 2 pounds in 1 week. C. The client demonstrates healthy coping mechanisms that decrease anxiety. D. The client verbalizes an understanding of the etiology of the disorder.

Correct Answer is C

Explanation

Choice A reason: Focusing conversations on nutritious food can be positive, but it does not directly indicate a change in behavior related to bulimia nervosa.

Choice B reason: Gaining weight may be a positive sign, but it is not sufficient on its own to indicate a behavioral change, as weight can fluctuate for various reasons.

Choice C reason: Demonstrating healthy coping mechanisms that decrease anxiety is a strong indicator of positive behavioral change in a client with bulimia nervosa, as it suggests the client is developing strategies to manage the disorder.

Choice D reason: While verbalizing an understanding of the disorder's etiology is beneficial, it does not necessarily reflect a change in behavior.

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The nurse is teaching a client with paranoid personality disorder to validate ideas with another person before taking action. Which statement made by the client indicates that the teaching is effective?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in the emergency department is creating a plan of care for a client experiencing alcohol intoxication. Which of the following interventions should the nurse plan to include? Select all that apply.

Correct Answer is ["A","C","D","E"]

Explanation

A client diagnosed with bulimia nervosa has been attending a mental health clinic for several months. Which factor should the nurse identify as an appropriate indicator of a positive client behavioral change?

Correct Answer is C

Explanation

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