A bystander was killed during a robbery 2 weeks ago. His widow, who is diagnosed with schizoaffective disorder, cries spontaneously when talking about his death. Select the nurse's most therapeutic response.

I am worried about how much you are crying. Your grief over your husband's death has gone on too long

"The unexpected death of your husband must be very painful. I am glad you are able to talk to me about your feelings."

"Are you hearing voices at night?"

"This loss is harder to accept because of your mental illness. I will refer you to a partial hospitalization program."

Answer and Explanation

The Correct Answer is B

A. This response minimizes her grief and implies pathology; crying after a recent traumatic loss is normal.
B. This response acknowledges the client’s pain, validates her feelings, and encourages continued expression, making it therapeutic.
C. This abruptly changes the subject and ignores her grief, which is the client’s primary concern.
D. This pathologizes normal grief and focuses on her diagnosis instead of providing empathy and support.

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Correct Answer is B

Explanation

A. Offering platitudes can minimize the patient’s feelings and may shut down further disclosure.
B. Directly asking about suicidal thoughts is the most important and therapeutic response because the statement expresses hopelessness, a major risk factor for suicide. This question assesses immediate safety and guides next steps (ask about intent, plan, means; implement suicide precautions and notify the provider as indicated).
C. Exploring past interests can be therapeutic later, but it does not address the immediate safety concern suggested by the patient’s hopeless statement.
D. Saying you don’t understand is vague and avoids addressing the potential crisis; a direct, nonjudgmental assessment of suicidal ideation is required.

A. Foot tapping and repeatedly writing the same phrase. B. Detachment and overconfidence. C. Euphoric mood, hyperactivity, distractibility. D. Darting eyes, tilted head, mumbling to self.

Correct Answer is D

Explanation

A. Foot tapping and repeatedly writing the same phrase suggest compulsive or stereotypic behavior, not hallucinations.
B. Detachment and overconfidence may indicate personality or mood disturbances, but not hallucinations.
C. Euphoric mood, hyperactivity, and distractibility are signs of mania, not auditory hallucinations.
D. Darting eyes, tilted head, and mumbling to self are classic behaviors seen when a patient is responding to internal stimuli such as auditory hallucinations.

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A bystander was killed during a robbery 2 weeks ago. His widow, who is diagnosed with schizoaffective disorder, cries spontaneously when talking about his death. Select the nurse's most therapeutic response.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A depressed patient says, "nothing matters anymore." What is the most appropriate response by the nurse?

Correct Answer is B

Explanation

A patient's care plan includes monitoring for auditory hallucinations. Which assessment findings suggest the patient may be hallucinating?

Correct Answer is D

Explanation

A patient diagnosed with schizophrenia has received fluphenazine decanoate twice a month for 3 years. The clinic nurse's notes that the patient grimaces and is constantly smacking his lips. The patient's neck and shoulders twist in a slow, snakelike motion. Which problem would the nurse suspect?

Which assessment finding would the nurse expect to see in a patient experiencing delirium? (Select all that apply)

A nurse in a substance abuse clinic is assessing a client who was recently prescribed disulfiram. The patient suddenly stopped taking this medication and is now complaining of severe nausea and vomiting. What should the nurse suspect is likely the cause of the client's distress?

A nurse is caring for a child who has autism spectrum disorder. Which of the following findings should the nurse expect? (Select all that apply).

A nurse is caring for a client in the emergency department (ED) Exhibits Which of the following client findings should the nurse report to the provider Immediately? (Select all that apply.)

Which measure would be considered a form of primary prevention for suicide?

A nurse is caring for a client who has bipolar disorder and a new prescription for valproate. Which of the following instructions should the nurse give the client al t about the use of this medication?

Which scenario demonstrates a dissociative fugue?