A nurse is caring for a client diagnosed with schizophrenia and is experiencing hallucinations. Which of the following actions should the nurse take?

Ask the client direct questions about the hallucination.

Act to the client as if the hallucination is real.

Tell the client to go to their room and they should go away.

Instruct the client to argue with the voices that are a part of the hallucination.

Answer and Explanation

The Correct Answer is A

The correct answer is choice A. Ask the client direct questions about the hallucination.

Choice A rationale:

Asking direct questions about the hallucination helps the nurse understand the client’s experience and assess the content and intensity of the hallucinations. This approach also allows the nurse to provide appropriate support and interventions.

Choice B rationale:

Acting as if the hallucination is real can reinforce the client’s distorted perception of reality, which is not therapeutic. The nurse should acknowledge the client’s experience without validating the hallucination as real.

Choice C rationale:

Telling the client to go to their room and that the hallucinations should go away is dismissive and does not address the client’s immediate needs. It is important to engage with the client and provide support rather than dismiss their experience.

Choice D rationale:

Instructing the client to argue with the voices can increase the client’s distress and is not a recommended therapeutic approach. Instead, the nurse should help the client find ways to cope with and manage the hallucinations.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A rationale:

An anxiety reaction is the most appropriate explanation for the toddler's behavior of sitting quietly in the corner of the crib, sucking her thumb, and turning away from the nurse. These behaviors suggest that the toddler is experiencing anxiety due to the absence of her mother. Sucking the thumb is a common self-soothing mechanism in young children, and the behavior of turning away from the nurse can be seen as an attempt to cope with the separation.

Choice B rationale:

Resentment toward the mother is less likely in this context, as the toddler's behavior is more indicative of distress and anxiety related to separation from her mother rather than directed resentment.

Choice C rationale:

Developing autonomy is not the primary explanation for these behaviors. While developing autonomy is an important developmental milestone for toddlers, the described behavior is more suggestive of anxiety and coping with separation rather than a deliberate expression of autonomy.

Choice D rationale:

Regression refers to reverting to an earlier developmental stage in response to stress or difficulty. While regression can occur in response to hospitalization and separation from caregivers, the toddler's behavior of sitting quietly and sucking her thumb is better explained by anxiety than by regression to an earlier developmental stage.

A. Misplacing car keys. B. Difficulty performing familiar tasks. C. Losing sense of time. D. Problems with performing basic calculations. E. Becoming lost in a usually familiar environment.

Correct Answer is ["B","C","D","E"]

Explanation

Choice A rationale:

Misplacing car keys is a common occurrence in many people's lives and is not necessarily indicative of Alzheimer's disease. It can happen to anyone due to various factors like stress or distraction.

Choice B rationale:

Difficulty performing familiar tasks is a potential early warning sign of Alzheimer's disease. This can include tasks that the person previously did with ease, such as cooking or dressing themselves. Alzheimer's disease affects cognitive abilities, including the ability to perform familiar tasks.

Choice C rationale:

Losing sense of time is another potential early warning sign of Alzheimer's disease. People with Alzheimer's may lose track of days or seasons, as the disease impacts their sense of time and memory.

Choice D rationale:

Problems with performing basic calculations can be a sign of cognitive decline, but it is not one of the primary early warning signs of Alzheimer's disease. This choice is less specific to Alzheimer's and could be related to other cognitive disorders as well.

Choice E rationale:

Becoming lost in a usually familiar environment is a significant early warning sign of Alzheimer's disease. Individuals with Alzheimer's may become disoriented even in places they know well, leading to confusion and anxiety. This is a result of the disease affecting their spatial memory and navigation skills.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is caring for a client diagnosed with schizophrenia and is experiencing hallucinations. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

When providing community healthcare teaching regarding the early warning signs of Alzheimer's disease, which signs should the nurse advise family members to report (Select all that apply)?

Correct Answer is ["B","C","D","E"]

Explanation

The nurse is reviewing the records of a child diagnosed with autistic spectrum disorder (ASD). Which of the following client outcomes should the nurse recognize as realistic for a client diagnosed with ASD?

A nurse is reviewing medication records for several clients who have bipolar disorder. The nurse should recognize that which of the following medications are used to treat clients who have bipolar disorder? (Select all that apply.).

A nurse is assessing a client who is withdrawing from alcohol. Which of the following findings should the nurse expect? (Select all that apply).

A nurse at a walk-in mental health clinic is assessing a client experiencing severe anxiety. The nurse should recognize the client might exhibit which of the following manifestations?

A nurse is caring for a client who has bipolar disorder. Which of the following actions by the client should the nurse interpret as displaying manic behavior? (Select all that apply.).

A nurse notices that a client who has moderate anxiety is pacing the corridor and rambling. As the nurse approaches, the client states, "I am at the end of my rope. I don't think I can take any more bad news." Which of the following responses should the nurse make?

A nurse in an acute care mental health facility is assessing a client who has bipolar disorder. The nurse recognizes that which of the following findings indicates the client is at risk for suicide?

During a family group therapy session, the nurse overhears the client telling her daughter, "You need to do better in school so I can love you as much as I love your brother." According to Warren, this statement discourages the development of positive self-esteem by hindering which parenting focus?