A nurse is conducting a group therapy meeting and is sharing a humorous story. When the group laughs at the story, a client diagnosed with schizophrenia jumps up and runs out while yelling, "You are all making fun of me." The nurse recognizes that which of the following behaviors is this client displaying?

Ideas of reference.

Erotomania.

Grandeur.

Flight of ideas.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Ideas of reference involve the belief that external events, objects, or people have a specific and unusual significance directly related to oneself. In this scenario, the client with schizophrenia believes that the group's laughter is directed at them, indicating an exaggerated sense of personal relevance in the situation.

Choice B rationale:

Erotomania is characterized by the delusional belief that someone, usually of higher social status, is in love with the individual. This choice is not applicable to the situation described, where the client's reaction is centered around perceived mockery rather than romantic interest.

Choice C rationale:

Grandeur involves inflated feelings of importance, power, knowledge, or identity. It does not align with the situation where the client perceives ridicule and responds defensively to the group's laughter.

Choice D rationale:

Flight of ideas is a thought disorder characterized by rapid and unconnected shifts in thoughts, often associated with mania. It is not relevant to the client's reaction to the group's laughter.

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Correct Answer is A

Explanation

The correct answer is choice A: "Come with me to an area where we can talk without interruption."

Choice A rationale:

The nurse's response of inviting the client to a quieter area for conversation demonstrates therapeutic communication. By offering a private space, the nurse acknowledges the client's distress and creates an environment conducive to open discussion. This response allows the client to express their feelings without the pressure of being observed or interrupted, fostering a sense of safety and trust.

Choice B rationale:

This response suggests recommending relaxation exercises, which might not be appropriate for a client in a heightened state of anxiety. While relaxation techniques can be helpful for managing anxiety, the client's current level of distress requires immediate attention and active engagement rather than advice on future interventions.

Choice C rationale:

Mentioning an antianxiety pill oversimplifies the situation and ignores the importance of therapeutic communication. Medication is not the primary intervention at this moment, and assuming that a pill would be the immediate solution could diminish the client's need to express their feelings and concerns.

Choice D rationale:

Suggesting that most clients with anxiety issues benefit from lying down is an inaccurate generalization. Different individuals have varying coping mechanisms, and the client's pacing and rambling indicate a need for active support and conversation, rather than a one-size-fits-all approach of lying down.

A. Identifying the client's coping skills. B. Protecting the client from injury to himself. C. Determining the cause of the client's anxiety. D. Ensuring that the client feels safe.

Correct Answer is B

Explanation

Choice A rationale:

Identifying the client's coping skills is an important assessment, but in the context of acute anxiety requiring crisis intervention, immediate safety takes precedence over assessment. Coping skills assessment can follow once the client is stable.

Choice B rationale:

Protecting the client from injury to himself is the highest priority in this scenario. Acute anxiety can lead to behaviors that pose a risk to the client's safety, such as self-harm or suicide. Ensuring the client's physical safety is paramount.

Choice C rationale:

Determining the cause of the client's anxiety is relevant for long-term care but not the immediate priority during crisis intervention. Immediate safety concerns must be addressed first.

Choice D rationale:

Ensuring that the client feels safe is important, but physical safety takes precedence. The client's subjective feeling of safety may not necessarily prevent them from engaging in harmful behaviors.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse notices that a client who has moderate anxiety is pacing the corridor and rambling. As the nurse approaches, the client states, "I am at the end of my rope. I don't think I can take any more bad news." Which of the following responses should the nurse make?

Correct Answer is A

Explanation

A nurse is caring for a client who requires crisis intervention for acute anxiety. Which of the following nursing actions is the highest priority?

Correct Answer is B

Explanation

A nurse is caring for a group of older adult clients. Which of the following manifestations indicates one of the clients is experiencing delirium?

A nurse is caring for a client diagnosed with schizophrenia and is experiencing hallucinations. Which of the following actions should the nurse take?

A nurse is assessing a client who is withdrawing from alcohol. Which of the following findings should the nurse expect? (Select all that apply).

A nurse is caring for an older adult client who was alert and oriented at admission but now seems increasingly restless and intermittently confused. Which of the following actions should the nurse take to address the client's safety needs?

A nurse is creating a plan of care for a client who is experiencing mania. Which of the following interventions should the nurse include in the plan?

A nurse in the ER is admitting a client who has experienced a weight loss of 11 kg (25 lb) in the past 3 months. The client weighs 40 kg (88 lb) and believes she is fat. Which of the following aspects of care should the nurse consider the first priority for this client?

A nurse is assessing a client who is sharing information regarding concerns about their marriage. The client states "My spouse and I argue most times." Which of the following statements by the nurse requires intervention by the charge nurse?

A nurse is caring for a client who lost all his possessions in a house fire and states, "I have no idea what I am going to do. I cannot think right now." Which of the following actions should the nurse take?