Question

A client with schizophrenia states, "The devil keeps telling me I am going to burn in hell." What is the appropriate nursing response?

Answer 1

Correct Answers:

"The voices must be scary for you. Would you like to talk more about how you are feeling."

Rationale :

🟠Therapeutic communication begins with acknowledging feelings; this response validates the client’s fear without reinforcing hallucination content.

🟠It uses empathy and reflection, which lowers anxiety and opens space for assessment of command hallucinations and suicide risk.

🟠The wording avoids arguing about reality, which can increase defensiveness in psychosis.

🟠Inviting the client to “talk more” is open-ended, promoting rapport and richer clinical data.

🟠This approach supports safety planning and collaboration while maintaining clear professional boundaries.

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Answer 2

Correct Answers:

Assign consistent staff members to care for this client.

Rationale :

♦️Clients with paranoid thinking benefit from predictability and consistency, which reduce misinterpretation and fear.

♦️Consistent staffing fosters trust formation, a prerequisite before more challenging interventions are effective.

♦️A stable nurse–client relationship decreases environmental stimuli and perceived threat, lowering agitation.

♦️Routine and familiar caregivers enhance medication adherence and engagement in care.

♦️This foundation enables later steps like psychoeducation and gradual socialization once trust is established.

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Answer 3

Correct Answers:

benztropine (Cogentin)

Rationale :

⏺️Extrapyramidal symptoms (EPS)—restlessness (akathisia), tremors, and involuntary muscle movements—reflect dopamine–acetylcholine imbalance from antipsychotics.

⏺️Benztropine is an anticholinergic that restores the neurotransmitter balance and rapidly relieves dystonia and parkinsonism.

⏺️It is a first-line agent for acute EPS while the primary antipsychotic plan is reviewed.

⏺️Nursing care includes monitoring for anticholinergic effects (dry mouth, blurred vision, constipation, urinary retention).

⏺️Early treatment prevents airway compromise in severe dystonia and improves treatment adherence.

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Answer 4

Correct Answers:

diphenhydramine (Benadryl)

Rationale :

✅Diphenhydramine has strong anticholinergic properties and is effective for acute dystonic reactions when benztropine is not tolerated.

✅It can be given IM or IV for rapid symptom relief, especially in emergent EPS.

✅This option is useful in clients with contraindications to anticholinergics or those who experience intolerable side effects.

✅Monitor for sedation and anticholinergic adverse effects while maintaining safety precautions.

✅Timely administration limits client distress and supports ongoing antipsychotic therapy.

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Answer 5

Correct Answers:

Initiate one-on-one supervision.
Remove potentially harmful objects from the room.
Determine history of suicide attempts.

Rationale :

Initiate one-on-one supervision

🟢The client’s hopelessness, behavioral “farewell” acts (giving away belongings), and sudden “peacefulness” signal imminent suicide risk.

🟢Continuous 1:1 observation prevents access to means and allows immediate intervention during high-risk windows.

🟢Close monitoring supports ongoing suicide risk reassessment and real-time de-escalation.

🟢It also facilitates medication/safety checks and ensures adherence to the safety plan.

🟢Documentation of observations and interventions strengthens team communication and continuity of care.

Remove potentially harmful objects from the room

🟢A ligature- and weapon-free environment is a core element of suicide precautions.

🟢Remove belts, cords, glass, sharps, and excess medications to reduce opportunity for impulsive self-harm.

🟢 Environmental rounds each shift maintain ongoing hazard control.

🟢This measure complements 1:1 supervision, creating layers of safety.

🟢Family/visitors are educated to avoid bringing restricted items, sustaining a safe milieu.

Determine history of suicide attempts

🟢A past suicide attempt is the strongest predictor of future suicide risk.

🟢 Detailed assessment of method, intent, planning, lethality, and rescue factors informs the level of precautions.

🟢Using validated tools (e.g., C-SSRS) enhances risk stratification and care planning.

🟢Findings direct targeted interventions (e.g., means restriction, intensive therapy, pharmacologic support).

🟢Ongoing review of history supports collaborative discharge planning and relapse prevention.

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Answer 6

Correct Answers:

"Let's talk more about what triggers you to drink alcohol."

Rationale :

☑️This open-ended, nonjudgmental prompt invites the client to explore internal and external triggers for relapse.

☑️It aligns with motivational interviewing, enhancing autonomy and readiness to change.

☑️Identifying patterns (conflict, emotions, places) enables personalized coping strategies and relapse prevention planning.

☑️The focus stays on the client’s current experience, which is clinically actionable and therapeutic.

☑️The tone promotes rapport, reduces shame, and supports goal-oriented behavior change.

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Answer 7

Correct Answers:

Anhedonia.
Affective blunting.
Alogia.

Rationale :

Anhedonia

🟣Anhedonia refers to the inability to experience pleasure, a hallmark negative symptom of schizophrenia.

🟣It contributes to social withdrawal and reduced interest in previously enjoyable activities.

🟣This symptom interferes with motivation and engagement in therapy or daily routines.

🟣Unlike positive symptoms, anhedonia is often persistent and less responsive to antipsychotic medications.

🟣Recognition helps nurses plan structured activities and promote behavioral activation strategies.

Affective blunting

🟣Affective blunting is the reduction in the expression of emotions, such as flat or restricted affect.

🟣Clients may show limited facial expression, monotone speech, and minimal gestures, leading others to misinterpret them as uninterested.

🟣This symptom impacts social interactions and can increase isolation.

🟣It is a key negative feature that distinguishes schizophrenia from purely mood-related disorders.

🟣 Nursing care should include clear communication, patience, and supportive engagement.

Alogia

🟣Alogia refers to poverty of speech or reduced verbal output due to disrupted thought processes.

🟣Clients may give brief or empty responses, making assessment and interaction more difficult.

🟣This symptom reflects cognitive slowing and is classified as a negative manifestation.

🟣Nurses should use short, direct questions and allow extra time for responses.

🟣Identifying alogia ensures appropriate interventions to facilitate communication and reduce frustration.

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Answer 8

Correct Answers:

The client reports a family history of psychosis.

Rationale :

🎯Genetic predisposition is one of the strongest risk factors for schizophrenia and related psychotic disorders.

🎯Clients with a first-degree relative who has psychosis have a significantly higher lifetime risk of developing similar conditions.

🎯Environmental stressors may act as triggers, but the underlying vulnerability is often hereditary.

🎯Nurses should consider family history when assessing mental health risks and planning preventive care.

🎯Early recognition of risk factors allows for timely education, monitoring, and intervention.

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Answer 9

Correct Answers:

The client is withdrawing from alcohol and may need treatment to prevent seizures.

Rationale :

🟠Symptoms such as tachycardia, hypertension, tremors, and anxiety 9 hours after last drink are consistent with early alcohol withdrawal.

🟠Without treatment, withdrawal may progress to seizures or delirium tremens, which are life-threatening.

🟠The nurse must recognize this as a medical emergency requiring benzodiazepine therapy.

🟠Monitoring vital signs, fluid status, and electrolytes is essential in preventing complications.

🟠Early identification and intervention reduce the risk of mortality in alcohol withdrawal.

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Answer 10

Correct Answers:

Try to make arrangements to interview the woman alone.

Rationale :

♦️Privacy is critical when assessing for intimate partner violence (IPV) because abusers often control responses.

♦️Interviewing the woman alone provides a safe environment for honest disclosure.

♦️The nurse demonstrates respect, trust-building, and advocacy by ensuring confidentiality.

♦️This strategy aligns with legal and ethical obligations to screen for abuse.

♦️It increases the likelihood of identifying IPV and initiating appropriate interventions and referrals.

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NUR180 Mental Health Exam 2 SU 25 DET C,

No.

1 :
A client with schizophrenia states, "The devil keeps telling me I am going to burn in hell." What is the appropriate nursing response?

2 :
A client with schizophrenia is hallucinating and experiencing paranoid thinking. Which nursing intervention would promote in developing trust interventions with this client?

3 :
During an assessment of a patient diagnosed with schizophrenia, the nurse observes new symptoms of restlessness, tremors, involuntary abnormal skeletal muscle movements. Which medication would the nurse expect to give this client?

4 :
Which medication would a nurse expect to administer when a client is experiencing extrapyramidal symptoms (EPS) and is unable to tolerate an anticholinergic like benztropine (Cogentin)?

6 :
The nurse is talking with a male client regarding his recent alcohol relapse. The client's statement hints to the idea that he started to drink again after a fight with his wife. What is the best therapeutic response to the patient?

7 :
The nurse is doing a staff education in-service regarding the clinical manifestation of schizophrenia. Which of the following should the nurse identify as negative symptoms of schizophrenia? (Select all apply)

8 :
Which of the following clients is most at risk for an acute psychotic episode?

9 :
The nurse is caring for a client with alcohol substance use disorder. The client stated their last drink was 9 hours ago. The client's HR is 118, BP 166/94 and has shaky hands. How does the nurse interpret this information?

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NUR180 Mental Health Exam 2 SU 25 DET C,

No.

1 : A client with schizophrenia states, "The devil keeps telling me I am going to burn in hell." What is the appropriate nursing response?

2 : A client with schizophrenia is hallucinating and experiencing paranoid thinking. Which nursing intervention would promote in developing trust interventions with this client?

3 : During an assessment of a patient diagnosed with schizophrenia, the nurse observes new symptoms of restlessness, tremors, involuntary abnormal skeletal muscle movements. Which medication would the nurse expect to give this client?

4 : Which medication would a nurse expect to administer when a client is experiencing extrapyramidal symptoms (EPS) and is unable to tolerate an anticholinergic like benztropine (Cogentin)?

6 : The nurse is talking with a male client regarding his recent alcohol relapse. The client's statement hints to the idea that he started to drink again after a fight with his wife. What is the best therapeutic response to the patient?

7 : The nurse is doing a staff education in-service regarding the clinical manifestation of schizophrenia. Which of the following should the nurse identify as negative symptoms of schizophrenia? (Select all apply)

8 : Which of the following clients is most at risk for an acute psychotic episode?

9 : The nurse is caring for a client with alcohol substance use disorder. The client stated their last drink was 9 hours ago. The client's HR is 118, BP 166/94 and has shaky hands. How does the nurse interpret this information?

1 :
A client with schizophrenia states, "The devil keeps telling me I am going to burn in hell." What is the appropriate nursing response?

2 :
A client with schizophrenia is hallucinating and experiencing paranoid thinking. Which nursing intervention would promote in developing trust interventions with this client?

3 :
During an assessment of a patient diagnosed with schizophrenia, the nurse observes new symptoms of restlessness, tremors, involuntary abnormal skeletal muscle movements. Which medication would the nurse expect to give this client?

4 :
Which medication would a nurse expect to administer when a client is experiencing extrapyramidal symptoms (EPS) and is unable to tolerate an anticholinergic like benztropine (Cogentin)?

6 :
The nurse is talking with a male client regarding his recent alcohol relapse. The client's statement hints to the idea that he started to drink again after a fight with his wife. What is the best therapeutic response to the patient?

7 :
The nurse is doing a staff education in-service regarding the clinical manifestation of schizophrenia. Which of the following should the nurse identify as negative symptoms of schizophrenia? (Select all apply)

8 :
Which of the following clients is most at risk for an acute psychotic episode?

9 :
The nurse is caring for a client with alcohol substance use disorder. The client stated their last drink was 9 hours ago. The client's HR is 118, BP 166/94 and has shaky hands. How does the nurse interpret this information?