Question

A nurse is performing an admission assessment for a client who has schizophrenia. Which of the following findings should the nurse identify as a negative symptom?

Answer 1

Correct Answers:

Affective flattening

Rationale :

🧠Negative symptoms of schizophrenia involve reductions or absence of normal emotional and behavioral functions, such as affective flattening, alogia (poverty of speech), avolition (lack of motivation), and anhedonia (inability to feel pleasure).

🧠Affective flattening refers to diminished emotional expression, seen as reduced facial expression, poor eye contact, and monotone voice.

🧠In contrast, somatic delusions, illogicality, and bizarre behavior are positive symptoms, which reflect excesses or distortions of normal functioning (e.g., hallucinations, delusions, disorganized thinking).

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Answer 2

Correct Answers:

Ask the client to agree to talk to a nurse whenever she feels the urge to exercise.

Rationale :

🟢Clients with anorexia nervosa often use excessive exercise as a maladaptive coping mechanism to control weight.

🟢A therapeutic nursing action is to set behavioral contracts or agreements that provide structure and encourage the client to seek support rather than engage in harmful activity.

🟢Asking the client to talk to a nurse when she feels the urge to exercise promotes trust, accountability, and alternative coping strategies.

🟢Restricting, reprimanding, or praising appearance is non-therapeutic and can worsen resistance or reinforce distorted body image.

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Answer 3

Correct Answers:

Remain with the client for a while.

Rationale :

⭐ Presence provides safety: During panic-level anxiety, clients are overwhelmed and unable to process information or participate in group or cognitive interventions. The nurse’s calm, supportive presence helps reduce feelings of isolation and provides reassurance.

⭐ Therapeutic communication: Simply remaining with the client conveys acceptance and support without demanding verbal interaction, which may be overwhelming at this stage.

⭐ Stabilization before interventions: Group therapy, rest suggestions, or medications may be considered later, but the immediate priority is to establish safety and trust through presence.

⭐ De-escalation of anxiety: The nurse’s calm demeanor can help the client begin to regain a sense of control and decrease escalating panic symptoms.

⭐ Foundation for further care: Once stabilized, the client will be better able to engage in coping strategies, rest, or structured therapy.

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Answer 4

Correct Answers:

Plan the client's schedule to allow time for rituals.

Rationale :

🔷 Compulsions reduce anxiety: In OCD, compulsive behaviors are performed to temporarily relieve overwhelming anxiety. Abruptly stopping or limiting rituals can increase distress and agitation.

🔷 Preserve therapeutic alliance: Allowing time for rituals shows respect for the client’s coping mechanisms, which helps build trust and rapport during the early phase of admission.

🔷 Gradual approach: Once trust is established, the nurse can begin working with the client on developing healthier coping strategies and gradually decreasing time spent on rituals.

🔷 Structured flexibility: Incorporating ritual time into the schedule maintains unit order while meeting the client’s psychological needs.

🔷 Safety and functioning: Balancing rituals with daily activities ensures the client can still participate in care and therapy without escalating anxiety.

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Answer 5

Correct Answers:

Echolalia

Rationale :

💎 Definition: Echolalia is the repetition of words or phrases spoken by others, often seen in children and adults with autism spectrum disorder (ASD).

💎 Communication pattern: It reflects difficulties with social interaction and language development, where the client echoes speech instead of generating original responses.

💎 Core feature of ASD: Along with impaired social reciprocity and restricted, repetitive behaviors, echolalia is a hallmark finding.

💎 Differentiation: Ambivalence is more typical in schizophrenia, associative looseness in thought disorders, and expressive affect refers to outward emotional expression, not a symptom of ASD.

💎 Clinical importance: Recognizing echolalia helps nurses adapt communication techniques, using clear, simple, and consistent language.

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Answer 6

Correct Answers:

The client's motor development may be limited to gross motor activities

Rationale :

◼️ Intellectual Developmental Disorder (IDD): A neurodevelopmental disorder characterized by significantly below-average intellectual functioning (IQ < 70) and limitations in adaptive behavior (skills needed for daily life).

◼️ Moderate IDD (IQ 35–49): Clients function at the level of a second-grade child. They are capable of learning basic academics and simple communication but require supervision.

◼️ Gross Motor Development: Refers to large muscle movements such as walking, running, sitting, or climbing. Clients with moderate IDD can achieve these skills with training.

◼️ Fine Motor Development: Refers to small, precise movements (writing, buttoning, cutting with scissors). These are often limited in moderate IDD, leading to reliance on caregivers for complex tasks.

◼️ Adaptive Needs: Clients can perform basic ADLs (feeding, dressing) with moderate assistance but will not achieve complete independence.

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Answer 7

Correct Answers:

Empowerment of the client to make decisions related to individual health care

Rationale :

🌱 The recovery model prioritizes client-centered care, where clients are active participants rather than passive recipients of treatment.

🌱 Its core principle is empowerment, giving clients the authority to make decisions regarding their health and recovery journey.

🌱 This model fosters autonomy, self-direction, and control, improving confidence and long-term engagement in treatment.

🌱 Health professionals, including nurses, act as facilitators and partners, supporting but not controlling the recovery process.

🌱 Emphasizing empowerment enhances self-esteem, responsibility, and hope, which are vital for sustained mental health recovery.

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Answer 8

Correct Answers:

"I will assist you in getting out of bed and getting dressed."

Rationale :

🤝 Clients with depression often struggle with energy, motivation, and concentration, leading to difficulty performing activities of daily living (ADLs).

🤝 The nurse should provide supportive assistance to help initiate these tasks rather than leaving the client isolated or enforcing punitive rules.

🤝 Offering help with activities such as dressing or getting out of bed creates a therapeutic alliance and encourages gradual independence.

🤝 This approach respects the client’s condition while promoting engagement, structure, and routine, which are essential in managing depression.

🤝 The strategy balances empathy with therapeutic boundaries, motivating the client while maintaining dignity.

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Answer 9

Correct Answers:

"Restrict your child's intake of caffeine while she is taking this medication."

Rationale :

☕ Methylphenidate is a central nervous system (CNS) stimulant used to treat ADHD by increasing dopamine and norepinephrine levels.

☕ Combining methylphenidate with caffeine, another stimulant, can intensify side effects like insomnia, tachycardia, restlessness, and anxiety.

☕ Parents should be taught to limit caffeine-containing products such as coffee, energy drinks, and chocolate to avoid worsening these effects.

☕ Proper teaching also includes giving the medication early in the day to minimize sleep disruption and monitoring the child’s growth and appetite.

☕ Education ensures safe use, prevents adverse reactions, and improves adherence to the treatment plan.

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Answer 10

Correct Answers:

Primary Intervention

Rationale :

📚 Primary prevention focuses on stopping a problem before it begins, through education, health promotion, and risk reduction.

📚 Teaching high school students about the dangers of drug abuse is a classic example, aiming to prevent initial experimentation and dependency.

📚 This level of prevention differs from secondary prevention, which involves early detection and intervention, and tertiary prevention, which involves rehabilitation after illness develops.

📚 Nurses play a key role in community and school health, using education as a tool to promote healthy decision-making in adolescents.

📚 By addressing drug abuse early, primary prevention reduces the incidence and burden of substance-related disorders in society.

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QLexNursing

1 :
A nurse is performing an admission assessment for a client who has schizophrenia. Which of the following findings should the nurse identify as a negative symptom?

2 :
A nurse is caring for a client who has anorexia nervosa and overexercises to avoid gaining weight. Which of the following nursing actions should the nurse take?

3 :
A nurse on an inpatient mental health unit is admitting a client who has panic-level anxiety. After showing the client to his room, which of the following nursing actions is most therapeutic at this time?

4 :
A nurse in a mental health facility is planning care for a client who has obsessive-compulsive disorder (OCD) and is newly admitted to the unit. Which of the following actions should the nurse plan to take regarding the client's compulsive behaviors?

5 :
A nurse is caring for a client who has autism spectrum disorder. Which of the following findings should the nurse expect?

6 :
A client is diagnosed with moderate intellectual developmental disorder. Which developmental characteristic would the nurse identify as typical of a client diagnosed with moderate intellectual developmental disorder?

7 :
Which is the priority focus of recovery models?

8 :
A nurse is caring for a client who is depressed and refuses to participate in group therapy or perform activities of daily living. Which of the following statements should the nurse make to the client?

9 :
A nurse is teaching the parents of a child who has ADHD about methylphenidate. Which of the following statements should the nurse include in the teaching?

10 :
A school nurse provides education on drug abuse to a high school class. This nursing action is an example of which level of preventive care?

QLexNursing

1 : A nurse is performing an admission assessment for a client who has schizophrenia. Which of the following findings should the nurse identify as a negative symptom?

2 : A nurse is caring for a client who has anorexia nervosa and overexercises to avoid gaining weight. Which of the following nursing actions should the nurse take?

3 : A nurse on an inpatient mental health unit is admitting a client who has panic-level anxiety. After showing the client to his room, which of the following nursing actions is most therapeutic at this time?

4 : A nurse in a mental health facility is planning care for a client who has obsessive-compulsive disorder (OCD) and is newly admitted to the unit. Which of the following actions should the nurse plan to take regarding the client's compulsive behaviors?

5 : A nurse is caring for a client who has autism spectrum disorder. Which of the following findings should the nurse expect?

6 : A client is diagnosed with moderate intellectual developmental disorder. Which developmental characteristic would the nurse identify as typical of a client diagnosed with moderate intellectual developmental disorder?

7 : Which is the priority focus of recovery models?

8 : A nurse is caring for a client who is depressed and refuses to participate in group therapy or perform activities of daily living. Which of the following statements should the nurse make to the client?

9 : A nurse is teaching the parents of a child who has ADHD about methylphenidate. Which of the following statements should the nurse include in the teaching?

10 : A school nurse provides education on drug abuse to a high school class. This nursing action is an example of which level of preventive care?

1 :
A nurse is performing an admission assessment for a client who has schizophrenia. Which of the following findings should the nurse identify as a negative symptom?

2 :
A nurse is caring for a client who has anorexia nervosa and overexercises to avoid gaining weight. Which of the following nursing actions should the nurse take?

3 :
A nurse on an inpatient mental health unit is admitting a client who has panic-level anxiety. After showing the client to his room, which of the following nursing actions is most therapeutic at this time?

4 :
A nurse in a mental health facility is planning care for a client who has obsessive-compulsive disorder (OCD) and is newly admitted to the unit. Which of the following actions should the nurse plan to take regarding the client's compulsive behaviors?

5 :
A nurse is caring for a client who has autism spectrum disorder. Which of the following findings should the nurse expect?

6 :
A client is diagnosed with moderate intellectual developmental disorder. Which developmental characteristic would the nurse identify as typical of a client diagnosed with moderate intellectual developmental disorder?

7 :
Which is the priority focus of recovery models?

8 :
A nurse is caring for a client who is depressed and refuses to participate in group therapy or perform activities of daily living. Which of the following statements should the nurse make to the client?

9 :
A nurse is teaching the parents of a child who has ADHD about methylphenidate. Which of the following statements should the nurse include in the teaching?

10 :
A school nurse provides education on drug abuse to a high school class. This nursing action is an example of which level of preventive care?