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:

This statement is confrontational and may make the client defensive.

Choice B rationale:

This statement provides the client with a choice, promoting autonomy and encouraging self-care.

Choice C rationale:

This statement is forceful and does not respect the client’s autonomy.

Choice D rationale:

Ignoring the client’s lack of self-care does not address the issue and could potentially harm the client.

A. "I know you hear the voices, but I do not.”. B. "The voices are part of your illness.”. C. "How often do you hear the voices?". D. "What are the voices telling you?".

Correct Answer is D

Explanation

Choice A rationale:

While acknowledging the voices can be part of therapeutic communication, it’s not the first response a nurse should make.

Choice B rationale:

Telling the client that the voices are part of their illness can be helpful, but it’s not the first response a nurse should make.

Choice C rationale:

Asking about the frequency of the voices can be part of the assessment, but it’s not the first response a nurse should make.

Choice D rationale:

Asking what the voices are saying can help assess if the client is experiencing command hallucinations, which could pose a safety risk.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has been diagnosed with schizophrenia. The client has been wearing the same clothes for the past week and appears unkempt and unbathed. Which of the following statements should the nurse make to the client?

Correct Answer is B

Explanation

A nurse is caring for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following responses should the nurse make first?

Correct Answer is D

Explanation

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?

A nurse is caring for a young adult client who has acute schizophrenic disorder and tells the nurse, "Yesterday noon the sun moon went over the rover to see the lawnmower.”. Which of the following manifestations is the client exhibiting?

A nurse is caring for a client who has schizophrenia and is taking haloperidol. The nurse should monitor for which of the following adverse effects of haloperidol?

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 reviewing discharge instructions with a client who has bipolar disorder and is taking lithium. Which of the following manifestations should the nurse include as an indication of mild toxicity?

A nurse is teaching a client who has bipolar disorder about lithium. Which of the following statements should the nurse include in the teaching?.

A nurse is reviewing medication records for several clients who have bipolar disorder. The nurse should recognize that which of the following medications are used to treat clients who have bipolar disorder.(Select all that apply.).