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","C","E"]

Explanation

Rationale:

A. Nylon socks are generally not considered a risk for self-harm and can be safely kept with the client.

B. A glass-framed picture presents a risk as the glass could be broken and used for self-harm. This item should be taken home.

C. Lace-up tennis shoes have long laces that could be used for self-harm, making them unsafe for a client at risk of suicide.

D. Cotton underwear does not pose a significant risk for self-harm and can be kept with the client.

E. A necklace could be used for self-harm, such as strangulation, and should be taken home to ensure the client's safety.

A. The final 2 min B. The final 15 min C. The first 15 min D. The first 2 min

Correct Answer is C

Explanation

Rationale:

A. Observing the final 2 minutes is not sufficient for detecting acute transfusion reactions, which can occur at any time during the transfusion.

B. Observing the final 15 minutes is also not adequate; reactions can occur earlier.

C. The first 15 minutes is the most critical time for observing for transfusion reactions, as most reactions occur during this period.

D. The first 2 minutes are too brief to detect potential transfusion reactions, which typically manifest within the first 15 minutes.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on an acute care mental health unit is examining the belongings of a client who is being admitted following a suicide attempt. Which of the following belongings should the nurse ask the client's partner to take back home?(Select All that Apply.)

Correct Answer is ["B","C","E"]

Explanation

A nurse is caring for a client who has a prescription for one unit of packed RBCs. The nurse should plan to remain in the room with the client at which of the following times during the infusion to observe for a transfusion reaction?

Correct Answer is C

Explanation

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