The nurse understands that whether or not a client experiences a crisis as a result of a stressful situation depends on:

The client’s perception of the event, the availability of supports, and the availability of adequate coping mechanisms.

Previous experiences, the availability of medication, and the desire to cope.

Faith in the psychiatrist, the availability of financial resources, and previous level of functioning.

The time of day, the client’s mood, and the availability of escape from the situation.

Answer and Explanation

The Correct Answer is A

Choice A Reason:

The client’s perception of the event, the availability of supports, and the availability of adequate coping mechanisms.

This is the correct response. A client’s perception of a stressful event plays a crucial role in determining whether they experience a crisis. If the client views the event as overwhelming and beyond their ability to cope, they are more likely to experience a crisis. Additionally, the availability of social supports, such as family, friends, and community resources, can provide emotional and practical assistance, reducing the likelihood of a crisis. Adequate coping mechanisms, such as problem-solving skills, emotional regulation, and stress management techniques, also play a significant role in helping the client manage stress effectively.

Choice B Reason:

Previous experiences, the availability of medication, and the desire to cope.

While previous experiences can influence how a client responds to stress, they are not the sole determinants of whether a crisis will occur. The availability of medication can help manage symptoms of stress or anxiety, but it does not address the underlying perception of the event or the availability of supports. The desire to cope is important, but without adequate coping mechanisms and support, it may not be sufficient to prevent a crisis.

Choice C Reason:

Faith in the psychiatrist, the availability of financial resources, and previous level of functioning.

Faith in the psychiatrist and the availability of financial resources can provide some support, but they do not directly address the client’s perception of the event or their coping mechanisms. Previous level of functioning is important, but it is not the primary factor in determining whether a crisis will occur. The client’s current perception and available supports are more critical in this context.

Choice D Reason:

The time of day, the client’s mood, and the availability of escape from the situation.

The time of day and the client’s mood can influence their immediate response to stress, but they are not the primary determinants of whether a crisis will occur. The availability of escape from the situation may provide temporary relief, but it does not address the underlying perception of the event or the availability of supports and coping mechanisms.

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Correct Answer is ["A","B","D"]

Explanation

Choice A Reason:

Slowed psychomotor activity.

Slowed psychomotor activity is a hallmark of hypoactive delirium. Patients with this type of delirium often exhibit reduced physical movement and slower reaction times. This symptom can make hypoactive delirium more challenging to recognize compared to the more obvious agitation seen in hyperactive delirium.

Choice B Reason:

Impaired attention and concentration.

Impaired attention and concentration are common in all forms of delirium, including hypoactive delirium. Patients may have difficulty focusing, sustaining, or shifting attention, which can significantly impact their ability to engage in daily activities or follow conversations.

Choice C Reason:

Hallucinations and delusions.

While hallucinations and delusions can occur in delirium, they are more commonly associated with hyperactive delirium. Hypoactive delirium is characterized more by withdrawal and decreased responsiveness rather than the presence of hallucinations or delusions.

Choice D Reason:

Decreased alertness or responsiveness.

Decreased alertness or responsiveness is a key feature of hypoactive delirium. Patients may appear drowsy, lethargic, or less responsive to their environment. This can sometimes be mistaken for depression or fatigue, making it crucial to differentiate hypoactive delirium from other conditions.

Choice E Reason:

Agitation and restlessness.

Agitation and restlessness are characteristic of hyperactive delirium, not hypoactive delirium5. In hypoactive delirium, patients are more likely to be withdrawn and less responsive rather than agitated or restless.

A. Promote interaction with others. B. Encourage participation in group therapy activities. C. Decrease their anxiety and increase trust. D. Improve their relationship with their parents.

Correct Answer is C

Explanation

Choice A Reason:

Promote interaction with others.

While promoting interaction with others is important for clients with schizophrenia, it is not the primary priority. Social interaction can help improve social skills and reduce isolation, but it should come after establishing a sense of safety and trust. Clients with schizophrenia often experience significant anxiety and mistrust, which need to be addressed first to create a stable foundation for further therapeutic interventions.

Choice B Reason:

Encourage participation in group therapy activities.

Encouraging participation in group therapy activities is beneficial for clients with schizophrenia as it can provide support and help them develop social skills. However, similar to promoting interaction with others, this goal is secondary to decreasing anxiety and building trust. Clients need to feel safe and trust their caregivers before they can effectively engage in group therapy.

Choice C Reason:

Decrease their anxiety and increase trust.

This is the correct response. Decreasing anxiety and increasing trust are fundamental goals in the care of clients with schizophrenia. High levels of anxiety and mistrust can exacerbate symptoms and hinder the effectiveness of other therapeutic interventions. Establishing a trusting relationship and reducing anxiety can create a more stable and supportive environment, which is essential for the client’s overall well-being and progress.

Choice D Reason:

Improve their relationship with their parents.

Improving the client’s relationship with their parents can be an important aspect of their overall treatment plan, especially if family dynamics contribute to their condition. However, this goal is not the immediate priority. Addressing the client’s anxiety and building trust should come first, as these are critical for the client’s stability and ability to engage in family therapy effectively.

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The nurse understands that whether or not a client experiences a crisis as a result of a stressful situation depends on:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing assessment data collected from a post-operative patient. What assessment findings would serve as cues that the client may be experiencing hypoactive delirium? Select all that apply.

Correct Answer is ["A","B","D"]

Explanation

The nurse is caring for a client with schizophrenia. Which of the following would be a priority nursing goal for this client’s care?

Correct Answer is C

Explanation

A client with a diagnosis of schizophrenia says to the student nurse, “The mazurkas are coming. The mazurkas are coming.” The client’s use of the word ‘mazurka’ is most likely a/an:

Forty-eight hours after starting haloperidol, the client is observed standing by the nurse’s station with his neck arched sharply backward. The nurse recognizes that the client:

A client diagnosed with major neurocognitive disorder is exhibiting behavioral problems. At the change of shift, the client’s behavior escalates from pacing in the hallway to screaming and waving their arms while on the ground. Which of the following represents a priority for the nurse?

The nurse recognizes that a function of the Mental Status Exam is to:

A nurse in orientation is rotating to a psychiatric unit where they observe a client in seclusion. Which of the following statements by the nurse’s preceptor best explains the use of seclusion on a unit?

A client is admitted to an inpatient unit with a diagnosis of frontotemporal dementia. Which of the following aspects of a medical history would the nurse expect to see with this client? (Select All that Apply.)

A client is admitted to the Emergency Department (ED) after ingesting a large amount of diazepam. Which medication would the nurse expect the ED physician to order?