Question

The client confides they are "cheeking" benzodiazepine medication for later use. The client trusts the nurse not to tell anyone. What is the correct nursing action?

Answer 1

Correct Answers:

Remind the client that you are obligated to report any action that affects their safety

Rationale :

🔷 The nurse should explain that client safety takes priority over confidentiality when the client is misusing or saving medication.

🔷 “Cheeking” benzodiazepines creates risk for overdose, diversion, sedation, respiratory depression, and withdrawal complications.

🔷 The nurse should be honest and remind the client that information related to safety must be shared with the treatment team.

🔷 This response maintains therapeutic trust because the nurse does not secretly report the client without first clarifying limits of confidentiality.

🔷 The nurse should assess the reason for saving the medication and ensure safe medication administration going forward.

Say nothing to the client and tell the treatment team

🔷This protects safety, but it is not the best therapeutic response because it hides the nurse’s responsibility from the client.

🔷The nurse should be honest about the limits of confidentiality.

Tell the client to admit this to someone else to avoid violating their trust

🔷The nurse cannot shift responsibility to the client when medication misuse creates a safety concern.

🔷The nurse has a duty to report and intervene.

Encourage the client to take their pills

🔷Encouraging the client to take the medication does not address the safety issue of hoarding benzodiazepines.

🔷The nurse must report the behavior and prevent further cheeking.

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Answer 2

Correct Answers:

"l would like to end it all with sleeping pills."
"Voices say it is OK for me to kill all prostitutes."
"The next time I am driving, I am going to drive off the closest bridge."

Rationale :

“I would like to end it all with sleeping pills.”

🟢 This statement meets involuntary hospitalization criteria because it expresses suicidal intent with a possible method.

🟢 A client who states they want to end their life requires immediate safety assessment and protection.

🟢 Sleeping pills are a specific means that can cause overdose, respiratory depression, coma, and death.

🟢 The nurse should assess access to pills, intent, plan, previous attempts, and current level of supervision needed.

🟢 This statement shows danger to self, which is a major criterion for involuntary hospitalization.

“Voices say it is OK for me to kill all prostitutes.”

🟢 This statement indicates command hallucinations with homicidal content.

🟢 The client is describing voices that give permission to harm others, which creates a serious safety risk.

🟢 The nurse must assess intent, access to weapons, specific targets, and the client’s ability to resist the voices.

🟢 Threats involving harm to others meet criteria for emergency psychiatric evaluation and possible involuntary admission.

🟢 This statement reflects danger to others and requires immediate intervention.

“The next time I am driving, I am going to drive off the closest bridge.”

🟢 This statement shows clear suicidal intent with a specific plan involving a vehicle.

🟢 A plan to drive off a bridge places the client and the public at immediate risk.

🟢 The nurse should not allow the client to leave unsupervised and should initiate safety precautions.

🟢 The statement demonstrates danger to self, impaired safety judgment, and need for urgent psychiatric care.

🟢 This meets involuntary hospitalization criteria because the client is describing a potentially lethal act.

“Since I retired I have been so depressed.”

🟢 Depression is concerning and requires assessment, but this statement alone does not show imminent danger to self or others.

🟢 More assessment is needed to determine suicidal thoughts, plan, intent, or inability to care for self.

“My boss makes me so angry by always picking on me.”

🟢Anger toward another person does not automatically meet involuntary hospitalization criteria.

🟢 The statement does not include a threat, plan, or intent to harm the boss.

“I have been so tired lately, I just want to sleep for days.”

🟢Fatigue and wanting to sleep may occur with depression or medical illness.

🟢 This statement does not clearly show suicidal intent, homicidal intent, or inability to meet basic needs.

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Answer 3

Correct Answers:

False, fixed ideas incongruent with reality

Rationale :

🟣 A delusion is a false belief that remains fixed despite clear evidence that it is not real.

🟣 The belief is usually inconsistent with the client’s culture, situation, or reality.

🟣 Delusions may include paranoid, grandiose, somatic, religious, or persecutory themes.

🟣 The nurse should not argue with or reinforce the delusion, but should acknowledge the client’s feelings.

🟣 The safest response is to present reality calmly and focus on the client’s emotional experience.

Troublesome perception of external stimulus

🟣 This describes an illusion, where a real external stimulus is misinterpreted.

🟣A delusion is a false belief, not a sensory misperception.

Perceptions involving the five senses

🟣This describes hallucinations, which are false sensory experiences.

🟣Delusions involve beliefs rather than hearing, seeing, smelling, tasting, or feeling something.

Ideas about which the client has lack of total insight

🟣This wording is vague and does not clearly define a delusion.

🟣A delusion is specifically a fixed false belief that is not consistent with reality.

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Answer 4

Correct Answers:

"Watch for symptoms like spasms in your neck and eyes, shuffling gait and restlessness."

Rationale :

🟠 Haloperidol is a first-generation antipsychotic that can cause extrapyramidal symptoms.

🟠 Neck or eye spasms may indicate acute dystonia, which can be frightening and requires prompt treatment.

🟠 A shuffling gait can indicate pseudoparkinsonism, another medication-related motor effect.

🟠 Restlessness may indicate akathisia, which can feel extremely uncomfortable and may reduce medication adherence.

🟠 Teaching the client to report these symptoms early helps prevent complications and supports safe antipsychotic therapy.

“This medication will help you to function better in social situations.”

🟠 Haloperidol is primarily prescribed to reduce psychotic symptoms such as hallucinations, delusions, and severe agitation.

🟠This statement is too general and does not provide the most important safety teaching.

“A sleeping pill will be ordered if you cannot sleep.”

🟠The nurse should not promise that another medication will be prescribed.

🟠Sleep concerns should be reported and assessed by the healthcare provider.

“You will be able to stop using this drug before very long because it will stop your disordered thinking.”

🟠Antipsychotic therapy often requires ongoing use to prevent relapse.

🟠The client should not stop haloperidol abruptly without provider guidance.

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Answer 5

Correct Answers:

The client is smiling appropriately more often
There is more interaction with other clients
There is more interest shown in unit activities
The client performs activities of daily living independently

Rationale :

The client is smiling appropriately more often

🔵 Appropriate smiling shows improvement in flat affect, which is a negative symptom of schizophrenia.

🔵 Negative symptoms involve reduced emotional expression, low motivation, social withdrawal, and decreased pleasure.

🔵 Risperidone can help reduce negative symptoms and improve emotional responsiveness in some clients.

🔵 More appropriate facial expression suggests the client is becoming more emotionally engaged with the environment.

🔵 This is a positive outcome because it reflects improved affective expression.

There is more interaction with other clients

🔵 Increased interaction shows improvement in social withdrawal, a common negative symptom.

🔵 Clients with negative symptoms may isolate, avoid conversation, and show limited interest in relationships.

🔵 More social participation suggests improved motivation and engagement.

🔵 This outcome indicates the medication and treatment plan may be helping the client participate more fully.

🔵 Social engagement is an important marker of improved functioning in schizophrenia.

There is more interest shown in unit activities

🔵 More interest in unit activities shows improvement in avolition, which means reduced motivation.

🔵 Negative symptoms often cause the client to appear uninterested or emotionally disconnected.

🔵 Participation in activities suggests improved initiative, attention, and willingness to engage.

🔵 This response indicates the client is moving toward better functional ability.

🔵 Increased interest is an expected improvement when negative symptoms are minimized.

The client performs activities of daily living independently

🔵 Independent performance of activities of daily living shows improvement in motivation and functional capacity.

🔵 Negative symptoms can reduce self-care, grooming, hygiene, and daily routine participation.

🔵 Improved ADLs suggest the client has better energy, organization, and self-directed behavior.

🔵 This outcome is clinically meaningful because independence supports recovery and discharge readiness.

🔵 The nurse should continue reinforcing routines and monitoring for medication effects.

The client is sleeping 10 hours a night, and napping 2-3 times during the day

🔵Excessive sleep may suggest sedation, low energy, or medication side effects.

🔵It does not indicate improvement in negative symptoms.

The client reports feeling very little pleasure

🔵Feeling very little pleasure describes anhedonia, which is a negative symptom.

🔵This finding means symptoms persist rather than improve.

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Answer 6

Correct Answers:

Assault

Rationale :

🔶 Assault occurs when a nurse threatens a client in a way that causes fear of unwanted treatment or harm.

🔶 Saying an injection will be given if the client refuses a pill is a threatening statement.

🔶 The client has the right to refuse medication unless legal emergency criteria or specific orders apply.

🔶 The nurse should explore the reason for refusal and use therapeutic communication instead of coercion.

🔶 This statement is assault because it threatens forced medication before an actual unauthorized touching occurs.

Unintentional tort

🔶 An unintentional tort involves negligence or harm that occurs without intent, such as failing to follow safety standards.

🔶 This situation involves a deliberate verbal threat, not accidental harm.

Battery

🔶Battery occurs when there is actual unauthorized physical contact, such as giving an injection without consent.

🔶 In this situation, the nurse threatened an injection but did not physically administer it.

Malpractice

🔶Malpractice is professional negligence that causes harm because the nurse failed to meet the standard of care.

🔶 This question focuses on the legal meaning of a threat, which is assault.

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Answer 7

Correct Answers:

“I don't have any feelings for my family members."

Rationale :

🟡 Anhedonia is the reduced ability to feel pleasure, interest, or emotional connection.

🟡 A client who states they do not have feelings for family members may be showing emotional blunting or loss of pleasure in relationships.

🟡 Anhedonia is considered a negative symptom of schizophrenia.

🟡 Negative symptoms often reduce motivation, expression, social engagement, and enjoyment.

🟡 This statement best reflects decreased emotional pleasure and attachment.

“I know I need to take my medication on a regular basis to stay well.”

🟡 This statement shows insight and understanding of treatment adherence.

🟡It does not reflect loss of pleasure.

“I feel so happy that my family is coming to see me this weekend.”

🟡This statement shows emotional pleasure and anticipation.

🟡It is the opposite of anhedonia.

“I don't understand why I'm in this treatment facility.”

🟡 This statement shows poor insight or confusion about hospitalization.

🟡It does not specifically describe inability to experience pleasure.

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Answer 8

Correct Answers:

To help the client contact reality

Rationale :

🟤 Referring to the immediate environment helps the withdrawn client reconnect with reality-based stimuli.

🟤 Clients with schizophrenia may become internally focused due to hallucinations, delusions, or disorganized thinking.

🟤 Talking about concrete objects or events in the environment can help orient the client to the present moment.

🟤 This intervention supports grounding and reduces focus on internal psychotic experiences.

🟤 The primary purpose is to promote contact with reality in a calm and nonthreatening way.

To prevent lengthy silence

🟤 Silence can be therapeutic and does not always need to be prevented.

🟤 The goal is not simply to fill time but to support reality orientation.

To prevent a non-productive interaction

🟤Productive interaction is helpful, but this is not the primary therapeutic purpose.

🟤 The main goal is to help the client connect with reality.

To put the client at ease

🟤Environmental references may reduce anxiety, but comfort is not the main reason for the intervention.

🟤 The priority is reality-based communication.

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Answer 9

Correct Answers:

Hallucinations

Rationale :

🔴 Hallucinations are positive symptoms of schizophrenia because they represent an added abnormal experience.

🔴 Positive symptoms include hallucinations, delusions, disorganized speech, and grossly disorganized behavior.

🔴 Hallucinations may involve hearing, seeing, feeling, smelling, or tasting something that is not present.

🔴 Auditory hallucinations are especially common in schizophrenia.

🔴 The nurse should assess what the hallucination is saying, whether commands are present, and whether the client is at risk for harm.

Flat affect

🔴 Flat affect is a negative symptom because it reflects reduced emotional expression.

🔴 It is not an added psychotic experience.

Catatonia

🔴Catatonia is a psychomotor disturbance that may occur in schizophrenia.

🔴 It is not the best example of a positive symptom compared with hallucinations.

Depressed mood

🔴Depressed mood is an affective symptom and may occur with many psychiatric conditions.

🔴 It is not classified as a positive symptom of schizophrenia.

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Answer 10

Correct Answers:

Continual pacing back and forth

Rationale :

🟣 Catatonic behavior involves abnormal psychomotor activity that may appear as extreme immobility or excessive purposeless movement.

🟣 Continual pacing back and forth can represent increased motor activity when it is repetitive and not goal-directed.

🟣 Catatonia can also include stupor, rigidity, mutism, posturing, negativism, or waxy flexibility.

🟣 The nurse should assess safety, hydration, nutrition, exhaustion, and risk for injury.

🟣 This finding best reflects the motor disturbance associated with catatonic behavior among the choices given.

Command hallucinations

🟣 Command hallucinations involve hearing voices that tell the client to do something.

🟣This is a perceptual disturbance, not catatonic motor behavior.

Disorganized speech pattern

🟣 Disorganized speech reflects impaired thought organization.

🟣It is not the key motor feature expected with catatonia.

Somatic delusions

🟣 Somatic delusions are false beliefs about the body or body function.

🟣They are thought-content disturbances rather than catatonic behavior.

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QLexNursing

1 :
The client confides they are "cheeking" benzodiazepine medication for later use. The client trusts the nurse not to tell anyone. What is the correct nursing action?

2 :
A family member brings a relative to the local community hospital because the relative has been acting strange. Which statements meets involuntary hospitalization criteria? Select all that apply.

3 :
When the client is delusional, the nurse would observe that the client is having:

4 :
When the healthcare provider prescribes haloperidol 4 mg three times/day, what instructions should the nurse give to the client?

5 :
A client with schizophrenia who has negative symptoms is prescribed risperidone. Which outcomes indicates that the medication has minimized these symptoms? Select all that apply?

6 :
The client is suspicious and refuses to take their medication. The nurse says, "If you don't take this pill, I'll get a prescription to give you an injection." The statement made by the nurse is an example of what?

7 :
Which statement, made by a client diagnosed with schizophrenia indicates they are experiencing anhedonia?

8 :
A client diagnosed with schizophrenia has been withdrawn, the nurse may make reference to things in the immediate environment to help the client respond. What is the primary purpose is this intervention?

9 :
During a nursing assessment of a client with schizophrenia, what is a positive symptom you may observe?

10 :
A nurse has been assigned to a client with a diagnosis of schizophrenia who is having catatonic behavior. The nurse would expect to assess which of the following in this client?

QLexNursing

1 : The client confides they are "cheeking" benzodiazepine medication for later use. The client trusts the nurse not to tell anyone. What is the correct nursing action?

2 : A family member brings a relative to the local community hospital because the relative has been acting strange. Which statements meets involuntary hospitalization criteria? Select all that apply.

3 : When the client is delusional, the nurse would observe that the client is having:

4 : When the healthcare provider prescribes haloperidol 4 mg three times/day, what instructions should the nurse give to the client?

5 : A client with schizophrenia who has negative symptoms is prescribed risperidone. Which outcomes indicates that the medication has minimized these symptoms? Select all that apply?

6 : The client is suspicious and refuses to take their medication. The nurse says, "If you don't take this pill, I'll get a prescription to give you an injection." The statement made by the nurse is an example of what?

7 : Which statement, made by a client diagnosed with schizophrenia indicates they are experiencing anhedonia?

8 : A client diagnosed with schizophrenia has been withdrawn, the nurse may make reference to things in the immediate environment to help the client respond. What is the primary purpose is this intervention?

9 : During a nursing assessment of a client with schizophrenia, what is a positive symptom you may observe?

10 : A nurse has been assigned to a client with a diagnosis of schizophrenia who is having catatonic behavior. The nurse would expect to assess which of the following in this client?

1 :
The client confides they are "cheeking" benzodiazepine medication for later use. The client trusts the nurse not to tell anyone. What is the correct nursing action?

2 :
A family member brings a relative to the local community hospital because the relative has been acting strange. Which statements meets involuntary hospitalization criteria? Select all that apply.

3 :
When the client is delusional, the nurse would observe that the client is having:

4 :
When the healthcare provider prescribes haloperidol 4 mg three times/day, what instructions should the nurse give to the client?

5 :
A client with schizophrenia who has negative symptoms is prescribed risperidone. Which outcomes indicates that the medication has minimized these symptoms? Select all that apply?

6 :
The client is suspicious and refuses to take their medication. The nurse says, "If you don't take this pill, I'll get a prescription to give you an injection." The statement made by the nurse is an example of what?

7 :
Which statement, made by a client diagnosed with schizophrenia indicates they are experiencing anhedonia?

8 :
A client diagnosed with schizophrenia has been withdrawn, the nurse may make reference to things in the immediate environment to help the client respond. What is the primary purpose is this intervention?

9 :
During a nursing assessment of a client with schizophrenia, what is a positive symptom you may observe?

10 :
A nurse has been assigned to a client with a diagnosis of schizophrenia who is having catatonic behavior. The nurse would expect to assess which of the following in this client?