A nurse on a mental health unit is assisting with the care of a client.

Exhibits

The nurse is continuing to assist with the care of the client. Select the four actions the nurse should take.

Ask the provider for a PRN prescription for restraints.

Administer diazepam when the client exhibits anxiousness.

Place the client in a room near the nurse's station.

Determine if the client is experiencing command hallucinations.

Establish clear limits for expected behaviors.

Answer and Explanation

Correct Answer : B,C,D,E

A. Ask the provider for a PRN prescription for restraints: Restraints should only be used as a last resort when there is an imminent risk of harm to the client or others. In this situation, it is essential to first attempt to manage the client's anxiety and behavior through de-escalation strategies and appropriate interventions.
B. Administer diazepam when the client exhibits anxiousness: Diazepam can help manage anxiety and agitation, which is crucial for the client's safety and comfort. Monitoring for signs of anxiety allows for timely intervention with the prescribed medication.
C. Place the client in a room near the nurse's station: Keeping the client close to the nurse's station allows for increased monitoring and ensures that staff can respond quickly if the client's behavior escalates. This helps maintain safety for both the client and others on the unit.
D. Determine if the client is experiencing command hallucinations: Assessing for command hallucinations is important, especially given the client's recent aggressive behavior. Understanding the presence of such hallucinations can guide the treatment plan and safety measures.
E. Establish clear limits for expected behaviors: Setting clear expectations for behavior helps the client understand acceptable conduct and promotes a safer environment. This can be particularly important for clients with paranoid personality disorder who may struggle with interpersonal relationships.

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Correct Answer is A

Explanation

A. "Before symptoms of schizophrenia begin, people often isolate themselves. This is an early warning.": This response provides an accurate explanation of a common behavior associated with the early stages of schizophrenia. It normalizes the client's experience by indicating that social withdrawal can be an early warning sign of developing symptoms, helping the client understand their condition better.
B. "Were you avoiding your friend so that you could hear the voices more clearly?": This response may come across as accusatory and could increase the client's anxiety or defensiveness. It does not promote a supportive dialogue about the client's experience and symptoms.
C. "That is very interesting. We are not sure why people start to isolate themselves.": While acknowledging the client's comment, this response lacks helpful information and does not provide insight into the relationship between isolation and the onset of schizophrenia symptoms. It misses an opportunity to educate the client about their condition.
D. "Do you think of yourself as more of an introvert? That makes a difference with how you socialize.": This question may divert the conversation from the client's experience with schizophrenia to a discussion about personality traits. It does not directly address the client's concern about isolation and the onset of their symptoms, making it less relevant to the situation.

A. Dissociative amnesia B. Factitious disorder C. Illness anxiety disorder D. Functional neurological symptom disorder

Correct Answer is B

Explanation

A. Dissociative amnesia: This diagnosis involves a loss of memory for personal information or events, typically following trauma or stress. It does not relate to intentionally causing injuries or symptoms.
B. Factitious disorder: Individuals with factitious disorder intentionally produce or feign physical or psychological symptoms to assume the role of a sick person. This behavior can include causing self-harm, such as breaking bones, to gain attention, sympathy, or care from others. The client's actions align with this diagnosis.
C. Illness anxiety disorder: Previously known as hypochondriasis, this disorder involves excessive worry about having a serious illness despite having no significant medical evidence. Individuals with this disorder do not intentionally cause harm to themselves; rather, they focus on perceived health concerns.
D. Functional neurological symptom disorder: This disorder involves neurological symptoms that cannot be explained by medical conditions. While individuals may have genuine neurological symptoms, they do not typically engage in self-harm or intentionally inflict injuries as seen in factitious disorder.

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A nurse on a mental health unit is assisting with the care of a client. Exhibits The nurse is continuing to assist with the care of the client. Select the four actions the nurse should take.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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A nurse on a mental health unit is assisting with the care of a client.

Exhibits

The nurse is continuing to assist with the care of the client. Select the four actions the nurse should take.