A nurse is caring for a client who has schizophrenia. The client suddenly moves to the corner of the room and shouts, "Get it away from me!" Which of the following actions should the nurse take?

Tell the client that there is nothing there.

Ask the client to describe what is being seen.

Touch the client's arm reassuringly.

Remove the client from the room.

Answer and Explanation

The Correct Answer is B

A. Tell the client that there is nothing there. Dismissing the client's perception may increase distress and reduce trust in the nurse-client relationship. A therapeutic approach acknowledges the client’s experience without reinforcing or denying hallucinations.
B. Ask the client to describe what is being seen. Encouraging the client to describe the hallucination helps assess its nature and severity. Understanding the content allows the nurse to provide appropriate support, ensure safety, and guide interventions.
C. Touch the client's arm reassuringly. Touching the client without consent, especially during a distressing hallucination, may escalate fear or agitation. Maintaining a calm and non-threatening presence is more appropriate.
D. Remove the client from the room. Relocating the client without assessing the hallucination may not address the underlying distress. Identifying triggers and using therapeutic communication are more effective initial interventions.

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Correct Answer is D

Explanation

A. "Lately, I feel like I am more alert than usual and can focus better.": Depression is commonly associated with difficulties in concentration, memory impairment, and slowed cognitive function rather than increased alertness or improved focus. Clients with depression often report feeling mentally sluggish or experiencing brain fog.
B. "I can't sit still. I feel like I need to be doing things around the house.": While some individuals with depression experience psychomotor agitation, it is more common for depression to present with fatigue, low energy, and decreased motivation. Restlessness may also be seen in anxiety disorders, but it is not a primary symptom of depression.
C. "When I went to my provider, they told me I have high blood pressure.": Hypertension is a medical condition that may have various causes, but it is not a direct manifestation of depression. However, chronic stress and depression can contribute to cardiovascular issues over time, though depression itself is primarily characterized by emotional and cognitive symptoms.
D. "I can't get my mind to stop racing at night. I'm only sleeping a couple of hours.": Insomnia and difficulty falling or staying asleep are hallmark symptoms of depression. Clients often experience ruminative thoughts, early-morning awakenings, or non-restorative sleep, which can contribute to worsened mood, fatigue, and impaired daily functioning.

A. Obsessive-compulsive disorder B. Schizophrenia C. General anxiety disorder D. Anorexia nervosa

Correct Answer is D

Explanation

A. "Obsessive-compulsive disorder.": Obsessive-compulsive disorder (OCD) is more commonly associated with cluster C personality disorders, particularly obsessive-compulsive personality disorder, which involves rigid perfectionism and a preoccupation with orderliness.
B. "Schizophrenia.": Schizophrenia is not a common comorbidity of cluster B personality disorders. It is more closely linked to schizotypal personality disorder, a cluster A disorder, which involves eccentric behaviors and cognitive distortions.
C. "General anxiety disorder.": Generalized anxiety disorder (GAD) is more frequently seen in cluster C personality disorders, such as avoidant and dependent personality disorders, which are characterized by excessive fearfulness and anxiety-driven behaviors.
D. "Anorexia nervosa.": Anorexia nervosa is commonly comorbid with cluster B personality disorders, particularly borderline personality disorder, due to emotional dysregulation, impulsivity, and an intense fear of abandonment that can contribute to disordered eating behaviors.

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A nurse is caring for a client who has schizophrenia. The client suddenly moves to the corner of the room and shouts, "Get it away from me!" Which of the following actions should the nurse take?

Nursing Test Bank

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