When the nurse admits a client with anorexia nervosa for treatment, the therapeutic milieu should provide: (SELECT ALL THAT APPLY)

observation during and after meals.

adherence to scheduled meal times.

trips to the local fast food restaurant for foods.

monitoring during bathroom trips.

weekly weight checks.

Answer and Explanation

Correct Answer : A,B,D

a. Observation during and after meals: To prevent the client from engaging in purging behaviors, such as vomiting or hiding food.

b. Adherence to scheduled meal times: To establish a regular eating pattern and help normalize the client’s relationship with food.

c. Trips to the local fast food restaurant for foods are not appropriate as they can promote unhealthy eating behaviors and do not align with the structured, therapeutic environment necessary for recovery.

d. Monitoring during bathroom trips: To prevent purging behaviors, especially right after meals when the temptation to vomit might be higher.

e. Weekly weight checks are important for monitoring progress, but daily or more frequent weight checks are often necessary to ensure safety and appropriate weight gain or stabilization.

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Correct Answer is A

Explanation

a. "There is a chemical imbalance of the brain, which leads to altered perceptions." Schizophrenia is a complex mental health disorder with a strong biological component. While the exact cause is unknown, it's believed to involve abnormalities in brain chemistry and neurotransmitters. This is a general explanation that avoids going into too much detail but acknowledges the biological basis of hallucinations.
b. "The hallucinations are caused by medication interactions." Hallucinations are a core symptom of schizophrenia and not necessarily caused by medication interactions.
c. "There is too little serotonin in the brain, causing delusions and hallucinations." While serotonin might be involved in schizophrenia, it's not the only neurotransmitter implicated.
d. Abnormal hormonal changes have precipitated auditory hallucinations." Hormonal changes might influence mood, but they are not the primary cause of auditory hallucinations in schizophrenia.

A. Altered thought processes; call an emergency treatment team meeting. B. Command hallucinations; warn the psychiatrist. C. Persecutory delusions; orient the client to reality. D. Magical thinking; administer an antipsychotic medication.

Correct Answer is B

Explanation

a. Altered thought processes; call an emergency treatment team meeting. While altered thought processes are present, the urgent concern is the command hallucination directing the client to harm the psychiatrist. An emergency treatment team meeting may not provide the immediate intervention required.
b. Command hallucinations; warn the psychiatrist. This is correct because the client is experiencing command hallucinations that pose a direct threat to the psychiatrist. The nurse has a duty to warn the potential victim and ensure the safety of both the client and others.
c. Persecutory delusions; orient the client to reality. Persecutory delusions are present, but the immediate danger from the command hallucinations takes precedence. Orienting the client to reality does not address the urgent safety issue.
d. Magical thinking; administer an antipsychotic medication. Magical thinking is not the correct symptom here. Administering medication is part of treatment but does not address the immediate safety concern.

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When the nurse admits a client with anorexia nervosa for treatment, the therapeutic milieu should provide: (SELECT ALL THAT APPLY)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 16-year-old client diagnosed with schizophrenia disorder experiences command hallucinations to harm others. The client's parents ask a nurse, "Where do the voices come from?" Which is the appropriate nursing response?

Correct Answer is A

Explanation

A client diagnosed with schizophrenia disorder states, "My psychiatrist is out to get me. I'm sad that the voice is telling me to stop the psychiatrist." What symptom is the client exhibiting, and what is the nurse's legal responsibility related to this symptom?

Correct Answer is B

Explanation

The nurse is assessing a client diagnosed with schizophrenia, who has been prescribed Haloperidol for the past year. On assessment, the nurse notices that the client is demonstrating bizarre facial and tongue movements. What is the priority nursing intervention?

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If a client demonstrates transference towards the nurse, how should the nurse respond?

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