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 :

🔷 Presents reality: This response gently corrects the hallucination by providing a factual explanation without arguing or reinforcing the false perception.

🔷 Therapeutic communication: A calm and non-confrontational reality orientation helps reduce anxiety and build trust.

🔷 Maintains safety: By clarifying the situation, the nurse helps the client feel more secure, which is essential during procedures like blood collection.

🔷 Avoids confrontation or dismissal: Statements like “You must be mistaken” or “Snakes cannot be in the clinic” are dismissive and may increase agitation in a hallucinating client.

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Answer 2

Correct Answers:

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

Rationale :

🔷 Encourages expression of feelings: Open-ended questions facilitate verbalization of emotions, which is essential for clients experiencing depression and grief.

🔷 Therapeutic communication: Asking about the relationship shows empathy and interest, helping the client process their loss.

🔷 Supports healthy grieving: Discussing memories can help the client work through their emotions rather than suppressing them.

🔷 Avoids minimizing feelings: The other options either invalidate the client’s experience or shift focus to the nurse, which is non-therapeutic.

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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 :

🔷 Weight often appears normal: Unlike anorexia nervosa, clients with bulimia nervosa typically maintain a normal or slightly above normal weight, making it harder to detect.

🔷 Hidden behaviors: Binge eating and purging are often done secretly, contributing to the delayed recognition of the disorder.

🔷 Medical complications: Despite normal weight, clients remain at risk for electrolyte imbalances, GI issues, and cardiac arrhythmias due to purging behaviors.

🔷 PSDA and diabetes are unrelated: The Patient Self-Determination Act (PSDA) and diabetes mellitus are not defining features of bulimia nervosa.

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Answer 4

Correct Answers:

Hypokinesis.

Rationale :

🟢 Rebound GI hyperactivity: Opioid withdrawal removes the drug’s normal GI-slowing effect, causing increased peristalsis and resulting in diarrhea.

🟢 Autonomic hyperstimulation: Withdrawal triggers sympathetic overdrive, leading to sweating, tachycardia, nausea, vomiting, and loose stools.

🟢 Characteristic withdrawal pattern: Clients often present with restlessness, rhinorrhea, abdominal cramping, and piloerection, consistent with acute withdrawal.

🟢 Opposite of opioid intoxication: Instead of bradycardia, hypokinesis, or meiosis, withdrawal causes tachycardia, hyperkinesis, and mydriasis (dilated pupils).

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Answer 5

Correct Answers:

Have consistent unit routines.

Rationale :

🔷 Promotes stability and structure: Clients in the manic phase of bipolar disorder benefit from predictable, consistent routines to reduce overstimulation and anxiety.

🔷 Decreases impulsivity: Structured schedules help manage hyperactivity and distractibility, common in mania.

🔷 Stimulating environments worsen mania: Providing stimulation or unpredictable changes can increase agitation and risky behaviors.

🔷 Rest is encouraged, not discouraged: Daytime rest may be necessary since sleep deprivation worsens manic symptoms. Seclusion is used only if safety is threatened, not as a routine intervention.

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Answer 6

Correct Answers:

“I tense and release my muscles, starting with my feet.”
“I think about being on my favorite beach vacation.”
Social support

Rationale :

1️⃣ A. “I tense and release my muscles, starting with my feet.” – ✅ Adaptive

🟢 Progressive muscle relaxation (PMR): This is a proven stress-reduction technique that decreases physical tension and promotes relaxation.

🟢 Physiological benefit: PMR lowers heart rate, blood pressure, and muscle tension, which are often elevated during stress.

🟢 Healthy coping mechanism: It is a constructive and safe way to manage anxiety without avoidance behaviors.

2️⃣ C. “I think about being on my favorite beach vacation.” – ✅ Adaptive

🟢 Guided imagery: Positive visualization, such as imagining a peaceful beach, activates the parasympathetic nervous system, promoting relaxation.

🟢 Cognitive reframing: Shifting focus to pleasant imagery helps reduce rumination on stressors and improves emotional regulation.

🟢 Common therapeutic strategy: Often used in mindfulness-based stress reduction (MBSR) programs.

3️⃣ E. “Social support.” – ✅ Adaptive

🟢 Healthy emotional outlet: Seeking support from friends, family, or support groups helps process emotions and reduces feelings of isolation.

🟢 Evidence-based benefit: Strong social connections are associated with lower stress hormone levels (cortisol) and better mental health outcomes.

🟢 Encourages problem-solving: Discussing concerns with others may lead to constructive solutions and enhanced coping capacity.

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Answer 7

Correct Answers:

“I will contact my provider if I have difficulty urinating.”

Rationale :

🟢 Anticholinergic side effects: Chlorpromazine, a typical antipsychotic, can cause urinary retention, constipation, dry mouth, and blurred vision due to its anticholinergic effects. Reporting difficulty urinating is essential to prevent urinary complications.

🟢 Endocrine effects differ: Instead of menstrual cycle frequency increasing, chlorpromazine may cause amenorrhea or galactorrhea due to increased prolactin levels.

🟢 Breast changes opposite to atrophy: The medication can cause gynecomastia or breast tenderness, not atrophy.

🟢 Infection risk increases, not decreases: Agranulocytosis or leukopenia are rare but serious adverse effects, so the risk for infection may actually increase.

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Answer 8

Correct Answers:

“You might experience some temporary memory loss after the procedure.”

Rationale :

🟢 Common expected effect: Electroconvulsive therapy (ECT) often causes short-term memory loss and confusion immediately after the procedure, which usually resolves over days to weeks.

🟢 Does not cure depression permanently: ECT is highly effective for severe depression, catatonia, or treatment-resistant mood disorders, but ongoing maintenance therapy or medications are typically required.

🟢 Seizure induction is therapeutic: Medications are given to induce muscle relaxation (e.g., succinylcholine) and anesthesia, not to prevent seizure activity, as the controlled seizure is essential for therapeutic effects.

🟢 Short anesthesia recovery: The client is typically awake and responsive 15–30 minutes after the procedure, not asleep for 2 hours.

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Answer 9

Correct Answers:

Pseudoparkinsonism

Rationale :

🟢 Characteristic symptoms: Pseudoparkinsonism, an extrapyramidal side effect of haloperidol, presents with stooped posture, shuffling gait, drooling, bradykinesia, and tremors, mimicking Parkinson’s disease.

🟢 Caused by dopamine blockade: Typical antipsychotics block dopamine receptors in the nigrostriatal pathway, leading to Parkinson-like motor symptoms.

🟢 Different from other EPS:

Acute dystonia: Involves sudden, sustained muscle contractions, such as torticollis or oculogyric crisis.

Akathisia: Marked by restlessness and inability to stay still.

Tardive dyskinesia: Involves involuntary movements like lip-smacking or tongue protrusion, usually after long-term therapy.

🟢 Treatment: Benztropine or diphenhydramine may be prescribed to relieve these symptoms.

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Answer 10

Correct Answers:

Withhold the medication.

Rationale :

🟢 Signs of lithium toxicity: Blurred vision and nausea are early manifestations of lithium toxicity, which can progress to more severe symptoms such as vomiting, diarrhea, tremors, and confusion.

🟢 Priority action – hold the drug: The nurse should withhold the lithium dose immediately and notify the provider to prevent worsening toxicity.

🟢 Serum lithium level required: The provider will likely order a lithium level test (therapeutic range: 0.6–1.2 mEq/L; toxic >1.5 mEq/L).

🟢 Other options inappropriate: Simply re-checking later, allowing rest, or giving the next dose could result in increased serum lithium levels and serious complications.

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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 planning care for a client who is in the manic phase of bipolar disorder. Which of the following interventions should the nurse include in the client's plan of care?.

6 :
A nurse facilitating a group therapy session is listening to clients discuss their coping strategies when feeling stressed. Which of the following statements indicate adaptive coping? (Select all that apply.)

7 :
A nurse is reinforcing teaching with a female client who is prescribed chlorpromazine. Which of the following statements by the client indicates an understanding of the teaching?

8 :
A nurse is reinforcing teaching with a client about electroconvulsive therapy (ECT). Which of the following information should the nurse include in the teaching?

9 :
A nurse is caring for a client who has schizophrenia and is taking haloperidol. The nurse observes that the client has developed a stooped posture and shuffling gait. The nurse should document these findings as which of the following extrapyramidal side effects of haloperidol?

10 :
A nurse is caring for a client who has bipolar disorder and is taking lithium. The client reports blurred vision and nausea. Which of the following actions should the nurse take?

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 planning care for a client who is in the manic phase of bipolar disorder. Which of the following interventions should the nurse include in the client's plan of care?.

6 : A nurse facilitating a group therapy session is listening to clients discuss their coping strategies when feeling stressed. Which of the following statements indicate adaptive coping? (Select all that apply.)

7 : A nurse is reinforcing teaching with a female client who is prescribed chlorpromazine. Which of the following statements by the client indicates an understanding of the teaching?

8 : A nurse is reinforcing teaching with a client about electroconvulsive therapy (ECT). Which of the following information should the nurse include in the teaching?

9 : A nurse is caring for a client who has schizophrenia and is taking haloperidol. The nurse observes that the client has developed a stooped posture and shuffling gait. The nurse should document these findings as which of the following extrapyramidal side effects of haloperidol?

10 : A nurse is caring for a client who has bipolar disorder and is taking lithium. The client reports blurred vision and nausea. Which of the following actions should the nurse take?

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 planning care for a client who is in the manic phase of bipolar disorder. Which of the following interventions should the nurse include in the client's plan of care?.

6 :
A nurse facilitating a group therapy session is listening to clients discuss their coping strategies when feeling stressed. Which of the following statements indicate adaptive coping? (Select all that apply.)

7 :
A nurse is reinforcing teaching with a female client who is prescribed chlorpromazine. Which of the following statements by the client indicates an understanding of the teaching?

8 :
A nurse is reinforcing teaching with a client about electroconvulsive therapy (ECT). Which of the following information should the nurse include in the teaching?

9 :
A nurse is caring for a client who has schizophrenia and is taking haloperidol. The nurse observes that the client has developed a stooped posture and shuffling gait. The nurse should document these findings as which of the following extrapyramidal side effects of haloperidol?

10 :
A nurse is caring for a client who has bipolar disorder and is taking lithium. The client reports blurred vision and nausea. Which of the following actions should the nurse take?