In Class Quiz

A client states that she hears God's voice telling her that she has sinned and needs to be punished. Which of the following nursing diagnoses is most appropriate? a. Disturbed sensory perception related to guilt as evidenced by auditory hallucinations b. Social isolation related to mistrust as evidenced by withdrawal behaviors c. Disturbed through process related to increased anxiety as evidenced by delusional thinking d. Impaired verbal communication related to disordered thinking as evidenced by loose associations

a

The client with a diagnosis of narcissistic personality disorder tells the nurse he can get an executive position with the best company around anytime he wants. The history reveals that the client, whose highest level of education completed is high school, has held only a series of short-term, part-time jobs for the past 2 years. The nurse interprets the client's statement to be an example of which of the following? a. Grandiose delusion b. Blatant lie c. Grandiose self-importance d. Sense of entitlement

a

A client who was diagnosed with undifferentiated schizophrenia 8 years ago is admitted to a unit because of increasingly severe mood swings. His diagnosis is changed to schizoaffective disorder. He asks the nurse, "So now what? My risperidone (Risperdal) is just not doing the job." How should the nurse respond? a. "The doctor will probably increase the dosage of your Risperdal." b. "With your mood swings, you may need to take a mood stabilizer along with your Risperdal." c. "The doctor will have to see how severe your mood swings are before he decides what to do." d. "If you are not suicidal, nothing will be done about your moods as we don't want to over medicate you."

b

A young client diagnosed with paranoid schizophrenia is talking with the nurse. "You know when I thought everyone was out to get me, I liked staying in my apartment all the time. Now, I'd like to get out and do things again." What is the best initial response by the nurse? a. "With whom do you want to do things?" b. "What activities did you enjoy in the past?" c. "What kind of transportation do you use?" d. "How much money can you spend?"

b

When developing the plan of care for a client receiving haloperidol (Haldol), which of the following medications would the nurse anticipate administering if the client developed extrapyramidal adverse effects? a. Lorazepam (Ativan) b. Benztropine mesylate (Cogentin) c. Paroxetine (Paxil) d. Olanzapine (Zyprexa)

b

The client who has a history of using angry outbursts when frustrated begins to curse at the nurse during an appointment after being informed that she will have to wait to have her medication refilled. Which of the following responses by the nurse is most appropriate? a. "You're being very childish." b. "I'm sorry if you can't wait." c. "I will not continue to talk with you if you curse." d. "Come back tomorrow and your medication will be ready."

c

Which of the following statements would indicate that family teaching about schizophrenia had been effective? a. "If our son takes his medication properly, he won't have another psychotic episode." b. "I guess we'll have to face the fact that our daughter will eventually be institutionalized." c. "It's a relief to find out that we did not cause our son's schizophrenia." d. "It is a shame out daughter will never be able to have children."

c

A client with borderline personality disorder has self-inflicted cuts on her arms. The nurse is assessing the client for the risk of suicide. What should the nurse ask the client first? a. About medications she has taken recently b. If she is taking antidepressants c. If she has a suicide plan d. Why she cut herself

d

The client approaches various staff with numerous requests and desires to the point of disrupting the staff's work with other clients. The nurse meets with the staff to decide on a consistent, therapeutic approach for the client. Which of the following approaches should the nurse expect to institute? a. Telling the client to stay in his room until staff approach him. b. Limiting the client to the dayroom and dining area. c. Giving the client a list of permissible requests. d. Having the client address needs to the staff person assigned

d

A client with mania is in the dining room at lunchtime and is observed taking food from other client's trays. The nurse's intervention should be based on which rationale? a. As soon as lunch is over, the client will calm down b. Other clients need to be protected from the intrusive behavior c. The client's behavior is not an imminent threat to anyone's physical safety d. The client needs food and fluids in any way possible

d manic pt. best to have finger food