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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Concrete thinking is a cognitive distortion characterized by a rigid and literal interpretation of events and experiences. Individuals with concrete thinking often struggle to grasp abstract concepts, metaphors, or multiple perspectives. They tend to view situations in black-and-white terms, with little room for nuance or ambiguity.
Statement A, "I am aware that each problem has only one solution," exemplifies concrete thinking in several ways:
Absolute language: The use of the phrase "each problem has only one solution" suggests a fixed and inflexible mindset. It implies that there is only one correct way to approach any given problem, disregarding the possibility of alternative solutions or perspectives.
Oversimplification: The statement reduces the complexity of problem-solving to a single, definitive answer. It fails to acknowledge the multifaceted nature of most problems, which often require creative thinking, flexibility, and consideration of multiple factors.
Lack of abstract
Intolerance of ambiguity: Concrete thinkers often experience discomfort with uncertainty or open-ended situations. They prefer clear-cut answers and definitive conclusions, which can lead to frustration and anxiety when faced with complex or ambiguous problems.
Correct Answer is D
Explanation
Choice A rationale:
Placing a client in restraints should be a last resort, as it can be traumatizing and can escalate agitation.
Restraints can also cause physical injury and psychological distress.
They should only be used when there is an immediate risk of harm to the client or others.
Choice B rationale:
Haloperidol is an antipsychotic medication that can be used to calm agitated clients.
However, it should not be the first-line intervention, as it can have significant side effects, including drowsiness, dizziness, and muscle stiffness.
It is important to assess the client's individual needs and risks before administering haloperidol.
Choice C rationale:
Asking a client to talk about their feelings can be helpful in some situations, but it is not appropriate when a client is agitated and yelling.
The client is likely to be too overwhelmed to engage in meaningful conversation.
It is important to first de-escalate the situation and ensure the safety of everyone involved.
Choice D rationale:
Moving the client to a seclusion room with continuous observation is the most appropriate intervention in this situation.
This will provide the client with a safe and quiet space to calm down.
It will also allow staff to monitor the client closely and intervene if necessary.
Continuous observation is essential to ensure the client's safety and to prevent self-harm.
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