A nurse is caring for a client who has depression.

After two days of treatment, the nurse notices that the client is suddenly more active and there are no longer signs of a depressive state.

Which of the following interventions should the nurse recommend for the plan of care?

Monitor the client’s whereabouts at all times.

Encourage family to take the client out of the facility for short periods of time.

Ask the client why her behavior has changed.

Reward the client for her change in behavior.

Answer and Explanation

The Correct Answer is A

Answer and explanation

Choice A rationale:

Impaired judgment is a cognitive symptom of schizophrenia, not a positive symptom. It involves difficulties with decisionmaking, problem-solving, and understanding consequences. While it's a significant feature of schizophrenia, it doesn't reflect an excess or distortion of normal functions, which is the hallmark of positive symptoms.

Choice B rationale:

Dysphoria refers to a depressed mood or a state of unhappiness and dissatisfaction. It's a negative symptom of schizophrenia, characterized by a decrease or absence of normal functions. It's not considered a positive symptom as it doesn't involve an excess or distortion of normal processes.

Choice C rationale:

Disorganized speech is a hallmark positive symptom of schizophrenia. It involves significant disruptions in the way a person speaks and communicates. It can manifest in several ways, including: Derailment: Abrupt shifts in topic without logical connection

Tangentiality: Responding to questions in irrelevant or oblique ways

Incoherence: Speech that is fragmented and difficult to understand

Loose associations: Combining words or phrases in a way that lacks logical sense

Neologisms: Creating new words or phrases that have meaning only to the speaker

Word salad: Severely disorganized speech that is essentially incomprehensible

Disorganized speech is considered a positive symptom because it reflects an excess or distortion of normal speech processes. It's a core feature of schizophrenia and often has a significant impact on communication and social functioning.

Choice D rationale:

Anhedonia is the inability to experience pleasure. It's a negative symptom of schizophrenia, characterized by a decrease or absence of normal emotional responses. It's not considered a positive symptom as it doesn't involve an excess or distortion of normal processes.

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Correct Answer is D

Explanation

The correct answer is D. Limit the client’s participation in group activities.

Explanation:

Clients with schizophrenia and paranoia may struggle in large group settings, where they could misinterpret interactions, feel threatened, or become agitated. Gradual integration into smaller, structured groups is typically recommended, rather than full exclusion, but limiting group participation can help reduce anxiety and prevent aggressive behaviors.

Why the other options are incorrect:

A. Place the client in seclusion if she is experiencing visual hallucinations – Seclusion is only used if the client poses a danger to themselves or others. Experiencing hallucinations alone does not warrant seclusion.
B. Minimize staff supervision of the client’s interactions with others – Increased supervision is necessary to ensure safety and monitor behavioral cues that may indicate escalating aggression.
C. Directly tell the client that delusions are not real – Confronting delusions outright can lead to agitation. Instead, acknowledge the client’s feelings while gently redirecting toward reality-based interactions.

A. Have consistent unit routines. B. Provide a stimulating environment. C. Schedule daily seclusion times. D. Discourage daytime napping.

Correct Answer is A

Explanation

The correct answer is Choice A.

Choice A rationale:

Having consistent unit routines can provide a sense of stability and predictability, which can be beneficial for a client in the manic phase of bipolar disorder.

Choice B rationale:

Providing a stimulating environment can potentially exacerbate symptoms of mania, making it an inappropriate intervention.

Choice C rationale:

Scheduling daily seclusion times is not typically recommended as it can lead to feelings of isolation.

Choice D rationale:

Discouraging daytime napping can potentially lead to fatigue and worsen symptoms, so it’s not typically recommended.

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A nurse is caring for a client who has depression. After two days of treatment, the nurse notices that the client is suddenly more active and there are no longer signs of a depressive state. Which of the following interventions should the nurse recommend for the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who has schizophrenia and experiences paranoia with aggressive behavior. Which of the following interventions should the nurse recommend to be included in the plan of care?

Correct Answer is D

Explanation

Explanation:

Why the other options are incorrect:

A nurse is planning care for a client who is in the manic phase of bipolar disorder. Which of the following interventions should the nurse include in the client's plan of care?.

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a client who has a history of depression about a new prescription for fluoxetine. Which statement by the client indicates understanding of the teaching?

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A nurse is reinforcing teaching with a client about electroconvulsive therapy (ECT). Which of the following information should the nurse include in the teaching?

A nurse is caring for a client who has schizophrenia and is taking haloperidol. The nurse should monitor the client for which of the following adverse effects?

A nurse in an acute care mental health facility is caring for a client who has major depression and states, “Everyone will be much better off when I’m gone.” Which of the following actions should the nurse take first?

A nurse is reinforcing discharge teaching with a client who has several new prescriptions for psychotropic medications. The client tells the nurse that she has always had trouble following a medication regimen. What should the nurse respond?

A nurse is contributing to the care plan for a newly admitted client suffering from severe depressive disorder. Which of the following interventions should the nurse incorporate into the plan?

A nurse is caring for a client who has depression.

After two days of treatment, the nurse notices that the client is suddenly more active and there are no longer signs of a depressive state.

Which of the following interventions should the nurse recommend for the plan of care?