Question

A nurse in a mental health facility is collecting a blood specimen from a client. The client is hallucinating and states, "That looks like a snake, and I won't let it take all of my blood.”. Which of the following responses should the nurse make?.

Answer 1

Correct Answers:

"I'm using a syringe to obtain your blood, not a snake.”.

Rationale :

🩸 This response uses therapeutic communication by presenting reality without arguing or dismissing the client’s hallucination.

🩸 Stating "I'm using a syringe to obtain your blood" helps orient the client to reality in a calm and factual manner, which is essential when managing hallucinations.

🩸 It avoids confrontation or invalidation, which could increase the client’s anxiety or mistrust.

🩸 Reality orientation is a key intervention for clients experiencing psychosis or hallucinations, helping them feel safer in their environment.

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Answer 2

Correct Answers:

"Tell me what your relationship with your partner was like.”.

Rationale :

🔷 This response demonstrates therapeutic communication by encouraging the client to express feelings and explore emotions related to the loss.

🔷 Asking about the relationship provides an opportunity for the client to verbalize grief, which is an essential step in the healing process.

🔷 It avoids giving false reassurance, making comparisons, or minimizing the client’s experience, which could hinder emotional processing.

🔷 Active listening and open-ended questions foster trust and help the nurse assess the depth of depressive symptoms and grieving process.

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Answer 3

Correct Answers:

"Bulimia nervosa is difficult to notice because a person might be of average or ideal body weight.”.

Rationale :

🍽️ Individuals with bulimia nervosa often maintain an average or ideal body weight, making the disorder harder to detect compared to anorexia nervosa.

🍽️ The disorder is characterized by recurrent episodes of binge eating followed by compensatory behaviors, such as vomiting, laxative misuse, or excessive exercise, regardless of body weight.

🍽️ Subtle physical signs, such as dental erosion, parotid gland swelling, and calluses on knuckles (Russell’s sign), may provide diagnostic clues.

🍽️ Early recognition is crucial to prevent serious complications, including electrolyte imbalances, cardiac dysrhythmias, and gastrointestinal damage.

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Answer 4

Correct Answers:

Diarrhea.

Rationale :

🔷 Opioid withdrawal is characterized by increased autonomic activity due to the absence of opioid suppression on the central nervous system.

🔷 Diarrhea is a common manifestation, along with abdominal cramping, nausea, vomiting, rhinorrhea, lacrimation, sweating, and piloerection.

🔷 Other expected findings include tachycardia, hypertension, dilated pupils (mydriasis), restlessness, and hyperreflexia.

🔷 Unlike opioid overdose, which causes bradycardia, respiratory depression, and miosis, withdrawal symptoms are uncomfortable but rarely life-threatening.

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Answer 5

Correct Answers:

Bupropion.

Rationale :

🚭 Bupropion is an atypical antidepressant approved for smoking cessation under the brand name Zyban.

🚭 It works by inhibiting the reuptake of norepinephrine and dopamine, reducing nicotine cravings and withdrawal symptoms.

🚭 Unlike nicotine replacement therapies, bupropion is non-nicotine based and can also help manage depressive symptoms that may arise during smoking cessation.

🚭 Other listed medications (aripiprazole, quetiapine, risperidone) are antipsychotics and are not indicated for smoking cessation.

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Answer 6

Correct Answers:

Low tolerance for frustration.

Rationale :

🔷 Low frustration tolerance is a significant risk factor for becoming a perpetrator of child abuse because it increases the likelihood of impulsive and aggressive responses to stress.

🔷 Individuals with this trait may have poor coping mechanisms and difficulty managing anger, especially under parenting stress.

🔷 A history of childhood physical abuse can contribute to learned patterns of aggression and poor emotional regulation, further increasing abuse risk.

🔷 Early interventions focusing on anger management, stress reduction, and parenting education can reduce the cycle of abuse.

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Answer 7

Correct Answers:

Improved mood.

Rationale :

🔷 Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) primarily used to treat depression, anxiety disorders, and some obsessive-compulsive symptoms.

🔷 The expected therapeutic outcome is an improved mood, increased energy, and better ability to perform daily activities as serotonin levels stabilize.

🔷 It is not indicated for preventing seizures, reducing tremors, or treating hallucinations, which are associated with other neurological or psychiatric conditions.

🔷 Full therapeutic effects generally appear after 2 to 4 weeks of consistent use, so patient education on adherence is essential.

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Answer 8

Correct Answers:

Verbally de-escalate the client.

Rationale :

🔷 Verbal de-escalation is the first-line intervention when early signs of agitation (e.g., clenched jaw, tense posture, change in voice pitch) are observed.

🔷 This approach helps reduce anxiety and aggression through calm communication, active listening, and reassurance, preventing the situation from escalating to violence.

🔷 Least restrictive interventions must always be attempted first before considering seclusion, restraints, or medications.

🔷 Early intervention using verbal techniques can preserve the therapeutic relationship and ensure safety for both the client and staff.

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Answer 9

Correct Answers:

Make a personal introduction to the client at each interaction.

Rationale :

🔷 Clients with dementia often experience memory loss and confusion, making it essential for the nurse to introduce themselves at every interaction to promote trust and orientation.

🔷 Repeatedly asking orientation questions until a correct response can cause frustration and agitation.

🔷 Offering long lists of choices can be overwhelming; instead, simple, limited options are preferred.

🔷 A dark environment may worsen disorientation and confusion; a well-lit, calm environment is safer.

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Answer 10

Correct Answers:

Acknowledge an inability to control drinking

Rationale :

🔷 The first step in alcohol recovery is for the individual to acknowledge a loss of control over alcohol use and recognize that drinking has become a problem.

🔷 This step aligns with the 12-step program principles (e.g., Alcoholics Anonymous), where admitting powerlessness over alcohol is key to initiating change.

🔷 Without acceptance of the problem, subsequent interventions—such as medications, support groups, or lifestyle changes—are unlikely to be effective.

🔷 Once acknowledgment occurs, the individual can then progress to forming support networks, engaging in therapy, and possibly incorporating spiritual or coping strategies.

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QLexNursing

1 :
A nurse in a mental health facility is collecting a blood specimen from a client. The client is hallucinating and states, "That looks like a snake, and I won't let it take all of my blood.”. Which of the following responses should the nurse make?.

2 :
A nurse is caring for a client who has depressive disorder following the recent death of their partner. Which of the following responses should the nurse make?.

3 :
A nurse is participating in a community program about eating disorders. Which of the following information about bulimia nervosa should the nurse include in the presentation?.

4 :
A nurse is collecting data from a client who is experiencing opioid withdrawal. Which of the following manifestations should the nurse expect?.

5 :
A nurse is providing information to a client about smoking cessation. Which of the following medications should the nurse include?.

6 :
A nurse is collecting data from a client who experienced physical abuse as a child. Which of the following findings should the nurse identify as a risk factor for the client to become a perpetrator of child abuse?.

7 :
A nurse is contributing to the plan of care for a client who is to start therapy with fluoxetine. Which of the following is an expected outcome for this client?.

8 :
A client is becoming increasingly agitated, anxious, and tense. The nurse notes a clenched jaw and a change in the pitch of the client's voice. Which of the following interventions should the nurse implement first?.

9 :
A nurse is assisting with the care of a client who has dementia. Which of the following actions should the nurse take?.

10 :
A nurse in a substance use disorder clinic is explaining the alcohol recovery process to a client's family. Which of the following should the nurse identify as the first step toward successful recovery from alcohol use disorder?.

QLexNursing

1 : A nurse in a mental health facility is collecting a blood specimen from a client. The client is hallucinating and states, "That looks like a snake, and I won't let it take all of my blood.”. Which of the following responses should the nurse make?.

2 : A nurse is caring for a client who has depressive disorder following the recent death of their partner. Which of the following responses should the nurse make?.

3 : A nurse is participating in a community program about eating disorders. Which of the following information about bulimia nervosa should the nurse include in the presentation?.

4 : A nurse is collecting data from a client who is experiencing opioid withdrawal. Which of the following manifestations should the nurse expect?.

5 : A nurse is providing information to a client about smoking cessation. Which of the following medications should the nurse include?.

6 : A nurse is collecting data from a client who experienced physical abuse as a child. Which of the following findings should the nurse identify as a risk factor for the client to become a perpetrator of child abuse?.

7 : A nurse is contributing to the plan of care for a client who is to start therapy with fluoxetine. Which of the following is an expected outcome for this client?.

8 : A client is becoming increasingly agitated, anxious, and tense. The nurse notes a clenched jaw and a change in the pitch of the client's voice. Which of the following interventions should the nurse implement first?.

9 : A nurse is assisting with the care of a client who has dementia. Which of the following actions should the nurse take?.

10 : A nurse in a substance use disorder clinic is explaining the alcohol recovery process to a client's family. Which of the following should the nurse identify as the first step toward successful recovery from alcohol use disorder?.

1 :
A nurse in a mental health facility is collecting a blood specimen from a client. The client is hallucinating and states, "That looks like a snake, and I won't let it take all of my blood.”. Which of the following responses should the nurse make?.

2 :
A nurse is caring for a client who has depressive disorder following the recent death of their partner. Which of the following responses should the nurse make?.

3 :
A nurse is participating in a community program about eating disorders. Which of the following information about bulimia nervosa should the nurse include in the presentation?.

4 :
A nurse is collecting data from a client who is experiencing opioid withdrawal. Which of the following manifestations should the nurse expect?.

5 :
A nurse is providing information to a client about smoking cessation. Which of the following medications should the nurse include?.

6 :
A nurse is collecting data from a client who experienced physical abuse as a child. Which of the following findings should the nurse identify as a risk factor for the client to become a perpetrator of child abuse?.

7 :
A nurse is contributing to the plan of care for a client who is to start therapy with fluoxetine. Which of the following is an expected outcome for this client?.

8 :
A client is becoming increasingly agitated, anxious, and tense. The nurse notes a clenched jaw and a change in the pitch of the client's voice. Which of the following interventions should the nurse implement first?.

9 :
A nurse is assisting with the care of a client who has dementia. Which of the following actions should the nurse take?.

10 :
A nurse in a substance use disorder clinic is explaining the alcohol recovery process to a client's family. Which of the following should the nurse identify as the first step toward successful recovery from alcohol use disorder?.