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 :

🟢 This response acknowledges the client’s feelings without reinforcing or denying the hallucination.

🟢 It demonstrates empathy and therapeutic communication, opening the door for the client to express emotions safely.

🟢 Confronting the hallucination directly (telling them it’s not real) can increase defensiveness, while agreeing with it reinforces delusions.

🟢 Offering support and active listening helps build trust and rapport, essential for clients with schizophrenia.

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Answer 2

Correct Answers:

Assign consistent staff members to care for this client.

Rationale :

🔵 Clients with schizophrenia, especially those with paranoia, require predictability and consistency in care.

🔵 Having the same staff fosters trust, reduces anxiety, and minimizes suspicion.

🔵 Encouraging group activities or challenging beliefs too soon can increase stress and mistrust.

🔵 Establishing a stable nurse-client relationship is the foundation for further interventions.

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Answer 3

Correct Answers:

benztropine (Cogentin)

Rationale :

🟡 Extrapyramidal symptoms (EPS) include restlessness, tremors, muscle rigidity, and abnormal involuntary movements caused by dopamine blockade from antipsychotics (e.g., haloperidol).

🟡 Benztropine is an anticholinergic that relieves EPS by restoring the dopamine-acetylcholine balance in the CNS.

🟡 This helps reduce tremors and muscle stiffness without worsening psychosis.

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Answer 4

Correct Answers:

diphenhydramine (Benadryl)

Rationale :

🟢 Extrapyramidal symptoms (EPS) are side effects of antipsychotics that include tremors, muscle rigidity, and dystonic reactions.

🟢 First-line treatment is usually benztropine (Cogentin), an anticholinergic.

🟢 If the client cannot tolerate benztropine due to side effects, diphenhydramine is given as an alternative because it also has anticholinergic properties.

🟢 It works by restoring balance between dopamine and acetylcholine in the central nervous system.

🟢 Nurses must monitor for sedation and anticholinergic effects such as dry mouth or blurred vision.

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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 :

A. Initiate one-on-one supervision

🟢 Clients with suicidal thoughts or behaviors require constant monitoring to ensure immediate safety.

🟢 One-on-one observation means a staff member remains with the client at all times, which helps prevent impulsive suicide attempts.

🟢 This intervention also provides an opportunity for therapeutic interaction, allowing the client to express emotions and feel supported.

🟢 It is considered the highest level of suicide precaution in acute care settings.

C. Remove potentially harmful objects from the room

🟣 Environmental safety is critical because suicidal clients may attempt self-harm with everyday items.

🟣 Objects such as sharp instruments, belts, shoelaces, medications, cords, and glass should be removed or secured.

🟣 Creating a safe space reduces access to means of suicide while other treatments and monitoring are in place.

🟣 This is one of the most immediate and effective nursing interventions to reduce risk.

D. Determine history of suicide attempts

🔵 A history of prior attempts is the strongest predictor of future suicide risk.

🔵 Assessing past behaviors provides insight into the client’s level of intent, method used, and likelihood of acting on thoughts again.

🔵 This information guides the care plan and level of observation required.

🔵 It also helps the healthcare team anticipate potential triggers and provide targeted support.

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Answer 6

Correct Answers:

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

Rationale :

🟢 This response reflects therapeutic communication because it is open-ended, nonjudgmental, and allows the client to explore the underlying reasons for relapse.

🟢 By focusing on triggers, the nurse helps the client identify situations, feelings, or conflicts (like the fight with his wife) that contribute to drinking behavior.

🟢 This approach empowers the client to recognize risky patterns and supports development of coping strategies for stress management.

🟢 It builds trust and shows empathy rather than dismissing or confronting the client harshly.

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Answer 7

Correct Answers:

Anhedonia
Affective blunting
Alogia

Rationale :

A. Anhedonia

🟢 Anhedonia is the inability to experience pleasure in activities that once brought enjoyment.

🟢 It is considered a negative symptom because it reflects a reduction in normal emotional functioning, rather than the addition of abnormal experiences.

🟢 Clients may appear disinterested in hobbies, relationships, or daily activities, which contributes to social withdrawal and isolation.

🟢 This loss of motivation can impair rehabilitation efforts and make recovery more challenging.

B. Affective blunting

🔵 Affective blunting refers to a significant reduction in emotional expression, often presenting as a flat affect or dull, unchanging facial expression.

🔵 It represents a loss of normal responsiveness, where clients may not show happiness, sadness, or concern even in emotionally charged situations.

🔵 This symptom interferes with social interactions and relationships, as others may perceive the client as uninterested or detached.

🔵 It is a hallmark negative symptom that often persists despite antipsychotic treatment.

E. Alogia

🟣 Alogia is a poverty of speech, marked by very brief or empty responses to questions.

🟣 It reflects impaired thought processes and reduced verbal productivity, making it difficult for clients to engage in conversation.

🟣 Nurses may notice delays in responses or one-word answers, even when more detail is expected.

🟣 This negatively impacts communication, trust building, and social functioning, requiring patience and supportive approaches from caregivers.

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Answer 8

Correct Answers:

The client reports a family history of psychosis.

Rationale :

🟣 Genetics is the strongest risk factor for schizophrenia and other psychotic disorders.

🟣 A family history indicates a biological predisposition, increasing likelihood of an acute psychotic episode under stress.

🟣 While stressors or behaviors may contribute, they are not as predictive as heredity.

🟣 Nurses must be alert to this risk for early recognition and intervention.

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Answer 9

Correct Answers:

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

Rationale :

🔴 Elevated HR, hypertension, tremors, and recent cessation of alcohol use are classic early withdrawal symptoms.

🔴 Alcohol withdrawal can progress to seizures or delirium tremens (DTs), which are life-threatening if untreated.

🔴 Treatment includes benzodiazepines, fluids, thiamine, and close monitoring.

🔴 Recognizing early withdrawal allows the nurse to prevent complications and maintain patient safety.

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Answer 10

Correct Answers:

Try to make arrangements to interview the woman alone.

Rationale :

🟢 Privacy is essential to allow the client to safely disclose abuse without the abuser’s presence.

🟢 Abusers often control conversations and intimidate victims, preventing them from speaking truthfully.

🟢 Interviewing the woman alone shows respect, promotes trust, and is a necessary step in abuse assessment.

🟢 The nurse must follow protocols but avoid direct confrontation in front of the partner, which may increase danger.

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NUR180 Mental Health Exam 2 SU 25

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 EPS symptoms and is unable to tolerate an anticholinergic like benztropine (Cogem

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

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 EPS symptoms and is unable to tolerate an anticholinergic like benztropine (Cogem

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 EPS symptoms and is unable to tolerate an anticholinergic like benztropine (Cogem

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?