A nurse is caring for a young adult client who has somatic symptom disorder and is being evaluated for chest pain.

The client's laboratory results are all within the expected reference ranges, the ECG is unremarkable, and the client has no identified cardiac risk factors.

Which of the following actions should the nurse take?

Refer the client for flooding therapy.

Inform the client that the pain is not real.

Provide reassurance to the client.

Encourage the client to request invasive cardiac testing.

Answer and Explanation

The Correct Answer is C

Choice A rationale:
Flooding therapy is not typically used for somatic symptom disorder.
Choice B rationale:
Telling a client that their pain is not real can invalidate their experience and is not a recommended approach for somatic symptom disorder.
Choice C rationale:
Providing reassurance to the client is a recommended approach when all tests are normal and there are no identified risk factors.
Choice D rationale:
Encouraging the client to request invasive cardiac testing is not typically recommended when all tests are normal and there are no identified risk factors.

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Correct Answer is B

Explanation

Choice A rationale:

Weight gain is not typically associated with acute mania in bipolar disorder.

Choice B rationale:

Disorganized speech can be a symptom of acute mania, which is characterized by increased energy, feelings of euphoria, racing thoughts, risky behaviors, and an inflated self-image.

Choice C rationale:

While hallucinations can occur in severe bipolar episodes, the client reporting that voices are telling him to write a novel is not specifically indicative of acute mania.

Choice D rationale:

Dressing in all black is not a specific symptom of acute mania.

A. Ensure the client goes to group activities as planned. B. Use distraction such as the television or music. C. Provide reassurance and comfort ensuring the client is safe. D. Give PRN medications to treat increased hallucinations.

Correct Answer is C

Explanation

Choice A rationale:
Ensuring the client goes to group activities as planned is important, but not the priority when the client is confused and has distorted thinking.
Choice B rationale:
Using distraction such as television or music can be helpful, but it is not the priority intervention.
Choice C rationale:
Providing reassurance and comfort ensuring the client is safe is the priority as it directly addresses the client’s immediate needs.
Choice D rationale:
Giving PRN medications to treat increased hallucinations may be necessary, but it is not the first action to take.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an acute mental health unit is admitting a client who has bipolar disorder. Which of the following findings supports the admitting diagnosis of acute mania?

Correct Answer is B

Explanation

A nurse is caring for a client who has been diagnosed with schizophrenia and appears confused and has distortions in their thinking and speech patterns. Which of the following is the priority nursing intervention for this client?

Correct Answer is C

Explanation

A nurse is caring for a client who has been prescribed clozapine. Which of the following topics should the nurse prepare to discuss with the client?.

A nurse is caring for a client who has bipolar disorder and is in the manic phase. The client says he is bored. Which of the following activities is appropriate for the nurse to suggest to this client?

Which nursing intervention will have the greatest impact on both the management of care and on milieu environment when considering the clients diagnosed with bipolar disorder?

A nurse is reviewing laboratory results for a client and notes a serum lithium level of 1.6 mEq/L. Which of the following manifestations should the nurse expect the client to report?.

A nurse is caring for a client who has schizophrenia and is experiencing a hallucination. Which of the following actions should the nurse take?

A nurse is caring for a group of clients at a mental health facility. The nurse should identify that which of the following clients is exhibiting a warning sign of suicide?

A nurse is discussing schizophrenia spectrum disorders with a client. The client states, "My friend says that before I started hearing voices, I stopped hanging out with them. Why is that?" Which of the following responses should the nurse make?

A nurse is educating a client who is prescribed clozapine. Which of the following findings should the nurse identify as consistent with agranulocytosis and instruct the client to monitor?