While sitting in the day-room of the mental health unit, a male adolescent avoids eye contact, looks at the floor, and talks softly when interacting verbally with the nurse. The two trade places, and the nurse demonstrates the client's behaviors. Which is the main goal of this therapeutic technique?

Initiate a non-threatening conversation with the client.

Allow the client to identify the way he interacts.

Dialog about the ineffectiveness of his interactions.

Discuss the client's feelings when he responds.

Answer and Explanation

The Correct Answer is B

A.   While initiating a non-threatening conversation with the client may be a goal of therapeutic communication, the main goal of this particular technique is to allow the client to identify his own behaviors by observing the nurse's demonstration.
B.   The main goal of this therapeutic technique is to allow the client to observe his own behaviors by seeing them demonstrated by the nurse, which can facilitate insight and self-awareness.
C.   Dialoguing about the ineffectiveness of his interactions may occur after the client has identified his behaviors, but it is not the primary goal of this specific technique.
D. Discussing the client's feelings when he responds may be part of the therapeutic process but is not the main goal of this particular technique, which focuses on self-observation and insight.

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Correct Answer is A

Explanation

A. Current vital signs are essential for assessing for neuroleptic malignant syndrome (NMS), a potentially life-threatening side effect of antipsychotic medications like haloperidol. Vital signs such as temperature, blood pressure, heart rate, and respiratory rate are crucial indicators of
NMS.

B. While monitoring white blood cell count may be important for detecting infections or adverse reactions to medications, it is not specific to assessing for NMS.
C. Monitoring 24-hour urinary output may be important for assessing renal function but is not specific to assessing for NMS.
D. Monitoring blood sugar levels may be important for clients with diabetes or those at risk of hyperglycemia due to medication effects, but it is not specific to assessing for NMS.

A. Ineffective sexual patterns. B. Disturbed sensory perception. C. Compromised family coping. D. Impaired environmental interpretation.

Correct Answer is B

Explanation

Rationale for A: Ineffective sexual patterns would not be the priority as the client's focus on sexual concerns appears to be delusional rather than a reflection of actual sexual dysfunction.

Rationale for B: The client is experiencing delusions, such as an inflated IQ and beliefs about being married to a movie star. These indicate altered perception of reality, making disturbed sensory perception the priority problem to address.

Rationale for C: Compromised family coping could be a concern but is not the primary issue in this situation. The client’s delusions take precedence as they directly impact his mental health and perception of reality.

Rationale for D: Impaired environmental interpretation refers to difficulty understanding the environment, but this client’s issue is more related to delusional thinking rather than misinterpretation of physical surroundings. Therefore, disturbed sensory perception is the more accurate nursing problem.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with schizophrenia returns to the clinic two weeks after receiving a prescription for haloperidol. To assess for neuroleptic malignant syndrome (NMS), which information is most important for the nurse to obtain during this visit?

Correct Answer is A

Explanation

A male client tells the nurse that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. Which is the priority nursing problem for admission to the psychiatric unit?

Correct Answer is B

Explanation

Mark which behaviors might be related to alcohol intoxication, acute phase of rape- trauma syndrome, or both. Tick only 1 box.

Which individual should the nurse consider at highest risk for suicide?

The nurse caring for this client is working with a new nurse. The nurse teaches the novice nurse about the legal and ethical issues surrounding the client's case. Mark whether the statement by the student nurse indicates understanding or no understanding.

A client who is an alcoholic receives a prescription for disulfiram 500 mg by mouth (PO) daily. Which instruction should the nurse provide to this client?

Which reason(s) should the nurse expect a female client to use when she is having difficulty leaving a relationship where she is a victim of intimate partner violence? Select all that apply.

A client with depression does not want to communicate with friends, uses television watching as a means of escaping responsibilities, and describes the inability to handle personal circumstances. Which coping strategy should the nurse include in the plan of care?