A 70yearold client is admitted to the locked psychiatric unit, diagnosed with delirium. Later in the day, he tries to get out of the locked unit several times. He yells, "I have to leave and get to my barber. I see him every Wednesday. Let me out!"

Which of the following would be the most therapeutic response by the nurse?

"You need to come and take a shower before you can go get your hair cut."

"Please stop banging on the door. Your room is right over there."

"The door is locked so that you don't leave and get hurt."

"You are in the hospital, and I'm your nurse."

Answer and Explanation

The Correct Answer is C

A.   This response does not directly address the client's concern and may be perceived as dismissive.
B.   This response does not provide a clear explanation for the locked door and may not effectively address the client's agitation.
C.   This response provides a clear and honest explanation for the locked door, ensuring the client's safety, which is the priority.
D.   This response acknowledges the situation but does not provide a clear explanation for the locked door.

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Correct Answer is C

Explanation

A. Flat affect (lack of emotional expression) and hygiene needs are negative symptoms, not positive symptoms.
B. Social isolation and anhedonia (inability to experience pleasure) are also negative symptoms, not positive symptoms.
C. Positive symptoms involve the presence of abnormal experiences or behaviors that are not present in healthy individuals. Hallucinations (perceiving things that aren't there) and delusions (strongly held false beliefs) are examples of positive symptoms.
D. Withdrawal (lack of interest or participation in social activities) and avolition (lack of motivation) are negative symptoms, not positive symptoms.

A. Allow him to continue the conversation at his own pace. B. Redirect the conversation to assist him in focusing on the topic. C. Stop him and tell him how his conversation sounds to others. D. Use the communication technique of reflecting.

Correct Answer is B

Explanation

A) Incorrect. Allowing the client to continue at his own pace may not effectively address the issue of circumstantiality and could lead to prolonged, tangential conversations.

B) Correct. Redirecting the conversation can help the client refocus and stay on topic, which can be particularly helpful for someone experiencing circumstantiality.

C) Incorrect. Stopping the client and telling him how his conversation sounds to others may be perceived as confrontational and could potentially be distressing for the client.

D) Incorrect. Reflecting is a useful communication technique, but it may not be the most effective intervention for addressing circumstantiality in this scenario.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse states in report that the client is experiencing positive symptoms of schizophrenia. What symptoms would the nurse receiving report expect to observe?

Correct Answer is C

Explanation

The nurse receives report on a male client diagnosed with schizoaffective disorder and is informed that the client's verbal communication includes "circumstantiality." What intervention is most therapeutic when caring for this client?

Correct Answer is B

Explanation

A nurse suspects the client is experiencing delirium. Which of the following assessment findings would support the nurse's suspicion?

While caring for a depressed client, a nurse would evaluate the need for suicide precautions under which circumstance?

A client diagnosed with bipolar II disorder has a problem statement of impaired social interactions related to egocentrism. Which short-term correctly written outcome is an appropriate expectation for this client problem?

What client population is at risk of developing tardive dyskinesia?

An older adult in the middle and late stages of Alzheimer's forgets where the bathroom is and has episodes of incontinence. Which intervention should the nurse suggest to the client's family?

The nurse is caring for a client who is withdrawing from long-term use of opioids. The nurse will monitor using a Clinical Opioid Withdrawal Scale (COWS). Which of the following cluster of symptoms would indicate to the nurse the client was withdrawing from opioids?

A nurse is providing teaching for a client who has schizophrenia and a new prescription for risperidone. Which of the following statements should the nurse include in the teaching?

The mother of a 20yearold woman recently diagnosed with paranoid schizophrenia asks the nurse what causes schizophrenia. The nurse recognizes which of the following are implicated in the etiology of schizophrenia?