Which component of the Mental Health Status Examination focuses on the way a person experiences reality?

Thinking/content of thought

Mood and affect

Judgment

Perception

Answer and Explanation

The Correct Answer is D

Choice A reason: Thinking/content of thought refers to the logical process of thought and coherence, not directly to the experience of reality.

Choice B reason: Mood and affect pertain to the emotional state and its expression, not the perception of reality.

Choice C reason: Judgment involves decision-making abilities and the evaluation of situations, not the perception of reality.

Choice D reason: Perception is the component that deals with how a person experiences reality, including any hallucinations or delusions they may have.

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Correct Answer is A

Explanation

Choice A reason: This response is empathetic and reassuring, affirming the nurse's role in providing care and support, which is essential in managing patients with schizophrenia who may experience feelings of paranoia or imprisonment.

Choice B reason: Asking if the patient feels they don't belong could reinforce feelings of alienation or paranoia. It's important to provide reassurance rather than question their sense of belonging.

Choice C reason: While deep breathing can be a calming technique, assuring the patient they will feel better may not address their immediate concerns or the reality of their feelings.

Choice D reason: Asking why they feel the need to leave could challenge the patient's experience and potentially escalate their distress. It's important to validate their feelings and provide reassurance.

A. Bounding pulse. B. Elevated temperature. C. Warmth at IV site. D. Profuse sweating. E. Crackles in lungs.

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

Explanation

Choice A reason: A bounding pulse can indicate fluid volume excess, as the heart works harder to pump the increased volume.

Choice B reason: Elevated temperature is not specifically indicative of fluid volume excess and can be related to various conditions.

Choice C reason: Warmth at the IV site may indicate an infection or inflammation, not necessarily fluid volume excess.

Choice D reason: Profuse sweating is not typically a sign of fluid volume excess; instead, it may indicate dehydration or other conditions.

Choice E reason: Crackles in the lungs can indicate fluid overload, especially in the context of excessive IV fluid administration.

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Which component of the Mental Health Status Examination focuses on the way a person experiences reality?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an acute care mental health facility is sitting with a client who has schizophrenia. The client whispers to the nurse, "I'm being kept in this prison against my will. Please try to get me out." Which of the following responses should the nurse make?

Correct Answer is A

Explanation

A patient is receiving IV fluids at 100 mL per hour. Which assessment findings would indicate fluid volume excess? (Select all that apply.)

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

Explanation

When setting limits with patients with personality disorders, the consequences of violating those limits should be set at which time?

The nurse is assisting in the care of a patient receiving an inhaled anesthetic. Which is a potential complication of inhaled anesthetics?

The nurse is reinforcing teaching provided to a patient with Raynaud's disease. Which measure should the nurse include to prevent an attack?

A nurse is collecting data from a client who has obsessive-compulsive personality disorder. Which of the following findings should the nurse include?

In the Mental Health Status Examination, which of the following focuses on what the person is thinking?

The nurse is caring for a client on the third day following abdominal surgery and assesses the absence of bowel sounds, abdominal distention, and the client passing no flatus. These findings indicate the client is experiencing which of the following postoperative complications?

A nurse is collecting data from a client who has anemia due to excessive blood loss during surgery. Which of the following findings should the nurse expect?

Mr. Thomas is chastised by his boss for failing to complete an assignment. When he arrives home, he slaps his son when the boy is slow in performing his chores. Mr. Thomas is displaying: