A nurse is caring for a client who has bipolar disorder. The client says to the nurse, “Give me your pen to cut the pain out of my chest.” The nurse should identify that the client is at risk for which of the following?
Illusion
Hallucination
Attention-seeking behavior
Self-mutilation
The Correct Answer is D
Choice A reason:
An illusion is a misinterpretation of a real external stimulus. For example, seeing a shadow and thinking it is a person. The client’s statement does not indicate a misinterpretation of reality but rather a desire to inflict harm on themselves.
Choice B reason:
A hallucination is a false sensory perception without any real external stimulus, such as hearing voices or seeing things that are not there. The client’s statement does not suggest they are experiencing a hallucination but rather expressing a desire to self-harm.
Choice C reason:
Attention-seeking behavior involves actions taken to gain attention from others. While the client’s statement could be seen as a cry for help, it is more accurately identified as a risk for self-mutilation due to the explicit mention of wanting to cut themselves.
Choice D reason:
Self-mutilation refers to deliberate self-inflicted harm, often as a way to cope with emotional pain. The client’s statement, “Give me your pen to cut the pain out of my chest,” clearly indicates a risk for self-mutilation, as they are expressing a desire to harm themselves to alleviate emotional distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Crisis care is an important component of the mental health care continuum, providing immediate support during acute episodes. However, it is not the primary goal of the continuum of care. The goal is to provide ongoing, comprehensive support that promotes stability and recovery.
Choice B reason:
Case management is a crucial aspect of mental health care, ensuring that clients receive coordinated and continuous services. While it plays a significant role in the continuum of care, it is not the overarching primary goal.
Choice C reason:
Coordination of care is essential for effective mental health treatment, involving the integration of various services and providers. However, it is a means to an end rather than the primary goal itself.
Choice D reason:
Care in the least restrictive environment is the primary goal of the mental health care continuum. This principle emphasizes providing care in settings that allow the greatest level of independence and normalcy for the client while ensuring their safety and well-being. It aims to avoid unnecessary institutionalization and promote community-based care.
Correct Answer is D
Explanation
Choice A reason:
“A relapse plan describes how you use coping strategies for living in the community.” While this is partially true, it does not fully capture the purpose of a relapse plan. A relapse plan is more comprehensive and includes recognizing early warning signs and taking specific actions to prevent a full relapse.
Choice B reason:
“A relapse plan addresses your living, housing, and working needs.” This statement is not accurate. A relapse plan focuses on managing symptoms and preventing relapse rather than addressing broader social needs like housing and employment.
Choice C reason:
“A relapse plan explains how you can be hospitalized if needed.” While hospitalization may be part of a relapse plan, the primary focus is on recognizing early symptoms and taking steps to manage them before hospitalization becomes necessary.
Choice D reason:
“A relapse plan helps your recovery by recognizing symptoms of schizophrenia and provides steps to follow if symptoms are getting worse.” This statement accurately reflects the purpose of a relapse plan. It emphasizes the importance of early recognition and proactive management of symptoms to support the client’s recovery.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
