Question

A nurse is creating a plan of care for a client who has schizophrenia and is experiencing command hallucinations. Which of the following interventions should the nurse include in the plan?

Answer 1

Correct Answers:

Maintain a low level of environmental stimuli.

Rationale :

💎 Clients experiencing command hallucinations may be more susceptible to overstimulation or confusion, which can exacerbate their symptoms.

💎 A low-stimulus environment helps reduce anxiety and distress, which may be triggered by excessive noise or activity.

💎 This intervention is crucial in creating a calm, safe environment, where the client can feel more in control of their thoughts and avoid acting on hallucinations.

💎 Other interventions, such as encouraging socialization or providing physical touch, might increase discomfort or trigger further hallucinations.

💎 Reducing stimuli allows the client to feel less overwhelmed and may facilitate better coping with their hallucinations.

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Answer 2

Correct Answers:

Preoccupation with details

Rationale :

🔷 A key characteristic of Obsessive-Compulsive Personality Disorder (OCPD) is preoccupation with orderliness, perfectionism, and control.

🔷 Clients with OCPD often focus on details, rules, and lists to the point where it interferes with task completion and relationships.

🔷 This preoccupation can lead to rigidity in behavior and difficulty adapting to change.

🔷 Other symptoms, such as lack of empathy or excessive clinging, are more characteristic of different personality disorders, such as narcissistic or dependent personality disorders.

🔷 Preoccupation with details is a hallmark feature of OCPD, distinguishing it from other disorders.

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Answer 3

Correct Answers:

Offer to contact the client’s spiritual advisor if they have one.

Rationale :

💠 Addressing a client's spiritual needs involves recognizing that spirituality plays an important role in coping with loss and grief.

💠 Offering to contact the client’s spiritual advisor provides appropriate support and respects the client’s personal beliefs during the grieving process.

💠 Internalizing feelings or changing the subject may disregard the client’s emotions, making it harder for the client to process grief.

💠 Offering emotional support through their spiritual community can be particularly meaningful to clients who rely on their faith during difficult times.

💠 It’s important to respect the client’s spiritual practices, which may offer comfort and meaning during the grieving process.

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Answer 4

Correct Answers:

Varenicline

Rationale :

💠 Varenicline is a medication specifically designed to help people quit smoking by reducing cravings and decreasing the satisfaction derived from smoking.

💠 It acts on the nicotinic receptors in the brain, providing partial stimulation to reduce withdrawal symptoms while blocking nicotine from affecting the brain.

💠 Naltrexone and disulfiram are used for alcohol dependence and opioid addiction, respectively, while donepezil is used to treat Alzheimer’s disease.

💠 Varenicline is the most appropriate choice for a client trying to quit smoking.

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Answer 5

Correct Answers:

Obtain a prescription for seclusion within 30 minutes.

Rationale :

🔷 Seclusion should only be used in cases of emergency when a client poses an imminent risk to themselves or others.

🔷 According to guidelines, a prescription for seclusion must be obtained within 30 minutes of its initiation, to ensure legal and ethical compliance.

🔷 Monitoring vital signs every 4 hours is not frequent enough, and documenting behavior every 60 minutes is not as timely or specific as needed.

🔷 The use of seclusion should always be time-limited, and its purpose is to ensure the safety of the client and others.

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Answer 6

Correct Answers:

"Lets discuss what you feel embarrassed about."

Rationale :

🔶 Therapeutic communication involves allowing the client to express emotions openly. 🔶By asking what the client feels embarrassed about, the nurse encourages the client to share their feelings.

🔶 This response fosters trust and allows the client to explore the source of their embarrassment without judgment.

🔶 Redirecting the focus by saying “everyone feels this way” or suggesting the client shouldn’t feel embarrassed dismisses their feelings.

🔶 The nurse's response should be non-judgmental and invite the client to express thoughts and emotions freely.

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Answer 7

Correct Answers:

The client is constantly talking.

Rationale :

💎 Constant talking or pressured speech is a hallmark sign of mania in bipolar disorder.

💎 During manic episodes, clients may experience increased energy, leading them to talk excessively and have racing thoughts.

💎 Other signs of mania include grandiosity, decreased need for sleep, and impulsive behavior, but talking constantly is the most indicative of this state.

💎 Memory loss, sleeping over 10 hours, and feelings of inferiority are more aligned with depression or other mental health conditions.

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Answer 8

Correct Answers:

Use short, simple sentences when speaking to the client.

Rationale :

🔷 When a client is experiencing moderate anxiety, they may have difficulty processing complex information.

🔷 The nurse should simplify communication by using short, clear sentences to enhance understanding and reduce confusion.

🔷 Detailed explanations or lengthy teaching can overwhelm the client and increase anxiety.

🔷 Asking too many questions or showing a video might add to stress and confusion.

💠 The goal is to provide clear, concise information that the client can easily absorb while experiencing anxiety.

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Answer 9

Correct Answers:

Use short, simple sentences when speaking to the client.

Rationale :

🔷 When a client is experiencing moderate anxiety, they may have difficulty processing complex information.

🔷 The nurse should simplify communication by using short, clear sentences to enhance understanding and reduce confusion.

🔷 Detailed explanations or lengthy teaching can overwhelm the client and increase anxiety.

🔷 Asking too many questions or showing a video might add to stress and confusion.

💠 The goal is to provide clear, concise information that the client can easily absorb while experiencing anxiety.

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Answer 10

Correct Answers:

"Can you tell me how you have been feeling lately?"

Rationale :

🔷 The client’s statement about giving away personal belongings may signal a loss of hope or pre-suicidal behavior, common in major depressive disorder.

🔷 By asking the client to describe their feelings, the nurse encourages the client to reflect on their emotional state, which can reveal underlying thoughts and concerns.

🔷 Asking about feelings allows the nurse to assess the client’s mental status and risk of self-harm while also providing the client an opportunity to express their emotions.

🔷 Why questions or dismissive statements like “everyone feels down” can make the client feel invalidated or not heard.

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QLexNursing

1 :
A nurse is creating a plan of care for a client who has schizophrenia and is experiencing command hallucinations. Which of the following interventions should the nurse include in the plan?

2 :
A nurse is caring for a client who has obsessive-compulsive personality disorder (OCPD). Which of the following findings should the nurse expect?

3 :
A nurse is caring for a client who is going through the grieving process. Which of the following actions should the nurse take to meet the clients’ spiritual needs?

4 :
A nurse is caring for a client who is seeking help to quit smoking. Which of the following prescriptions should the nurse expect the provider to prescribe?

5 :
A nurse in an acute care mental health facility is caring for a client who has been placed in seclusion following an acute violent episode. Which of the following actions should the nurse take?

6 :
A nurse is caring for a client who states, "l am too embarrassed to tell anyone what I did last night." Which of the following responses should the nurse make?

7 :
A nurse in a rehabilitation center is caring for a client who has bipolar disorder. Which of the following actions by the client indicates mania?

8 :
A nurse is preparing to teach a client who has moderate anxiety about what to expect after their upcoming cardiac catheterization. Which of the following actions should the nurse plan to take?

9 :
A nurse is preparing to teach a client who has moderate anxiety about what to expect after their upcoming cardiac catheterization. Which of the following actions should the nurse plan to take?

10 :
A nurse is caring for a client who has major depressive disorder and states that they have given away their personal belongings. Which of the following responses should the nurse make?

QLexNursing

1 : A nurse is creating a plan of care for a client who has schizophrenia and is experiencing command hallucinations. Which of the following interventions should the nurse include in the plan?

2 : A nurse is caring for a client who has obsessive-compulsive personality disorder (OCPD). Which of the following findings should the nurse expect?

3 : A nurse is caring for a client who is going through the grieving process. Which of the following actions should the nurse take to meet the clients’ spiritual needs?

4 : A nurse is caring for a client who is seeking help to quit smoking. Which of the following prescriptions should the nurse expect the provider to prescribe?

5 : A nurse in an acute care mental health facility is caring for a client who has been placed in seclusion following an acute violent episode. Which of the following actions should the nurse take?

6 : A nurse is caring for a client who states, "l am too embarrassed to tell anyone what I did last night." Which of the following responses should the nurse make?

7 : A nurse in a rehabilitation center is caring for a client who has bipolar disorder. Which of the following actions by the client indicates mania?

8 : A nurse is preparing to teach a client who has moderate anxiety about what to expect after their upcoming cardiac catheterization. Which of the following actions should the nurse plan to take?

9 : A nurse is preparing to teach a client who has moderate anxiety about what to expect after their upcoming cardiac catheterization. Which of the following actions should the nurse plan to take?

10 : A nurse is caring for a client who has major depressive disorder and states that they have given away their personal belongings. Which of the following responses should the nurse make?

1 :
A nurse is creating a plan of care for a client who has schizophrenia and is experiencing command hallucinations. Which of the following interventions should the nurse include in the plan?

2 :
A nurse is caring for a client who has obsessive-compulsive personality disorder (OCPD). Which of the following findings should the nurse expect?

3 :
A nurse is caring for a client who is going through the grieving process. Which of the following actions should the nurse take to meet the clients’ spiritual needs?

4 :
A nurse is caring for a client who is seeking help to quit smoking. Which of the following prescriptions should the nurse expect the provider to prescribe?

5 :
A nurse in an acute care mental health facility is caring for a client who has been placed in seclusion following an acute violent episode. Which of the following actions should the nurse take?

6 :
A nurse is caring for a client who states, "l am too embarrassed to tell anyone what I did last night." Which of the following responses should the nurse make?

7 :
A nurse in a rehabilitation center is caring for a client who has bipolar disorder. Which of the following actions by the client indicates mania?

8 :
A nurse is preparing to teach a client who has moderate anxiety about what to expect after their upcoming cardiac catheterization. Which of the following actions should the nurse plan to take?

9 :
A nurse is preparing to teach a client who has moderate anxiety about what to expect after their upcoming cardiac catheterization. Which of the following actions should the nurse plan to take?

10 :
A nurse is caring for a client who has major depressive disorder and states that they have given away their personal belongings. Which of the following responses should the nurse make?