A nurse is caring for a client who has schizophrenia with an exacerbation of hallucinations. The client states, "I do not understand why the hallucinations have come back." The nurse should explain that which of the following is the reason for the exacerbation of hallucinations?

Boundaries

Relapse

The SE model

Stigma

Answer and Explanation

The Correct Answer is B

Rationale:

A. Boundaries refer to maintaining professional limits in the nurse-client relationship, which is not directly related to the cause of hallucination exacerbation.

B. Relapse is the return of symptoms after a period of improvement, which is a common explanation for the recurrence of hallucinations in a client with schizophrenia.

C. The SE model (Social Ecological Model) is a framework for understanding the various levels of influence on health behaviors and is not a direct cause of hallucinations.

D. Stigma refers to the negative attitudes and beliefs about mental illness, which can affect a client’s self-perception but is not a direct cause of symptom exacerbation.

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Correct Answer is B

Explanation

Rationale:

A. Removing the PICC line should only be done if directed by a provider after further assessment.

B. The first action is to measure the circumference of both arms to assess for possible complications such as thrombosis or infiltration. This measurement will help determine the extent of the swelling and inform subsequent actions.

C. Notifying the provider is important but should be done after gathering relevant assessment data, such as the arm circumference.

D. Applying a cold pack may be appropriate for reducing swelling but is not the first step. Assessment should come first.

A. "My boss often asks me to work overtime, but I have to refuse the extra hours due to my responsibilities at home." B. "The demands of raising two young children by myself are often overwhelming, and I sometimes need some alone time to recharge." C. "On the weekends when my kids are with their other parent, I often just lay in bed all day and cry, because I feel hopeless." D. "Work can be extremely stressful at times, so I often need to take a walk during my lunch break."

Correct Answer is C

Explanation

Rationale:

A. This statement reflects a healthy boundary-setting behavior, where the client recognizes their limits and makes decisions accordingly.

B. This reflects a healthy coping mechanism, where the client acknowledges their stress and takes time to recharge, which is important for mental health.

C. This statement indicates a possible depressive symptom, as feeling hopeless and withdrawing from activities (like staying in bed and crying) can be signs of depression. This requires follow-up to assess the client's mental health and provide appropriate support.

D. Taking a walk during stressful times is a positive coping strategy that helps manage stress and maintain mental health.

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A nurse is caring for a client who has schizophrenia with an exacerbation of hallucinations. The client states, "I do not understand why the hallucinations have come back." The nurse should explain that which of the following is the reason for the exacerbation of hallucinations?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving total parenteral nutrition via a peripherally inserted central catheter (PICC). When assessing the client, the nurse notes swelling of the client's arm above the PICC insertion site. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

A nurse is discussing mental health with a client. Which of the following statements by the client requires follow-up by the nurse?

Correct Answer is C

Explanation

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