A nurse in an acute care mental health facility is contributing to the plan of care for a client who is newly diagnosed with schizophrenia and is verbalizing paranoid delusions. Which of the following interventions should the nurse include in the plan?

Set limits on the amount of time the client talks about delusions,

Schedule a variety of competitive stimulating group activities for the client

Tell the client that the delusions are not real

Avoid asking the client about triggers for the delusions

Answer and Explanation

The Correct Answer is A

A. Set limits on the amount of time the client talks about delusions. Clients with paranoid delusions may fixate on them, increasing distress and reinforcing their beliefs. The nurse should allow the client to express feelings but set limits on discussions about delusions to help refocus on reality-based topics.

B. Schedule a variety of competitive stimulating group activities for the client. Competitive activities can increase stress and paranoia in a client with schizophrenia. Instead, the nurse should encourage structured, low-stimulation activities like drawing or walking.

C. Tell the client that the delusions are not real. Directly challenging the delusions can increase defensiveness and mistrust.

D. Avoid asking the client about triggers for the delusions. Identifying triggers can help prevent or manage delusional episodes. The nurse should gently explore what makes the client feel more paranoid or anxious to develop coping strategies.

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Correct Answer is B

Explanation

A. Hyperexcitability is not typically associated with major depressive disorder. In fact, individuals with depression often experience a decrease in energy, motivation, and overall activity levels.

B. Significant change in weight.
Major depressive disorder (MDD) is often associated with changes in appetite and weight. Clients with MDD may experience either weight loss or weight gain. This can result from changes in eating habits related to the individual's emotional state.

C. Exaggerated response of pleasure to stimuli is not a characteristic finding in major depressive disorder. In contrast, individuals with depression may experience anhedonia, which is a reduced ability to experience pleasure from previously enjoyable activities.

D. Attention-seeking behavior is not a specific characteristic of major depressive disorder. Individuals with depression may withdraw socially and experience difficulties in concentration and attention.

A. Potassium 2.8 mEq/L B. Serum chloride 96 mEq/L C. Hgb 11g/dL D. Serum amylase 240 units/L

Correct Answer is A

Explanation

A. Potassium 2.8 mEq/L
Hypokalemia (low potassium) is a critical finding and a priority in individuals with a history of bulimia nervosa, as it can lead to life-threatening complications such as cardiac arrhythmias and muscle weakness. Frequent vomiting and laxative use, common behaviors in bulimia nervosa, can result in significant potassium loss. A potassium level of 2.8 mEq/L is significantly below the normal range and requires immediate attention.

B. Serum chloride 96 mEq/L: While this value is within the normal range, it should be monitored. However, it is not as critical as addressing severe hypokalemia.

C. Hemoglobin (Hgb) 11 g/dL: This hemoglobin level is within the normal range and does not require immediate attention. It may be influenced by factors other than bulimia nervosa, and addressing hypokalemia is more urgent.

D. Serum amylase 240 units/L: Elevated amylase levels may indicate pancreatic inflammation, which could be related to bulimia nervosa, but it is not as urgent as addressing severe hypokalemia. The priority is managing the life-threatening electrolyte imbalance first.

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A nurse in an acute care mental health facility is contributing to the plan of care for a client who is newly diagnosed with schizophrenia and is verbalizing paranoid delusions. Which of the following interventions should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has major depressive disorder (MDD). Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

A nurse is reviewing the admission laboratory values for a client who has a history of bulimia nervosa. Which of the following findings is the nurse's priority?

Correct Answer is A

Explanation

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