A nurse on an inpatient mental health unit is caring for a client.

Exhibits

The nurse is discussing the assessment findings on day 3 of admission during the 1900 change of-shift report. For each finding, specify whether the finding indicates potential improvement in or worsening of the client’s condition.

Giving away car

Hygiene

Food intake

Condition of skin on right hand

Rapid change in mood

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}

Indicates potential Improvement a. Hygiene b. Food intake c. Rapid change in mood

Indicates potential worsening a. Giving away car b. Condition of skin on right hand

Choice A: Giving away car

This could be a sign of the client’s worsening condition. Giving away possessions can sometimes be a sign of suicidal ideation. It’s important to monitor this behavior and report it to the healthcare provider.

Choice B: Hygiene

The client showered without prompting on the third day, which is an improvement from the first day when they declined to shower. Improved personal hygiene can be a sign of improvement in a client with obsessive-compulsive disorder.

Choice C: Food intake

The client ate 75% of their meals on the third day, which is an improvement from the first day when they refused to eat. Increased food intake can indicate an improvement in the client’s condition2.

Choice D: Condition of skin on right hand

The client’s hands remain reddened with a 1 cm x 1 cm area of peeling skin noted on the center of the right palm. This could indicate a worsening condition, as it may be a result of excessive handwashing, a common compulsion in OCD.

Choice E: Rapid change in mood

The client’s affect rapidly changed throughout the afternoon and early evening; the client is now talkative and appears content. This could indicate an improvement in the client’s condition, as they are engaging more with others and showing more positive emotions.

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Correct Answer is A

Explanation

Choice A reason: A blood glucose level of 256 mg/dL is significantly higher than the normal range and could indicate hyperglycemia, which is a serious side effect of risperidone. The provider should be notified immediately to manage this potential complication.

Choice B reason: A WBC count of 6,000/mm³ is within the normal range and does not typically warrant concern or the need to notify the provider.

Choice C reason: A platelet count of 250,000/mm³ is also within the normal range and is not indicative of an adverse reaction to risperidone.

Choice D reason: A sodium level of 140 mEq/L falls within the normal range and is not a cause for alarm in the context of risperidone therapy.

A. Assertiveness training B. Response prevention therapy C. Schema-focused therapy D. Cognitive behavioral therapy

Correct Answer is C

Explanation

Choice A reason: Assertiveness training is typically used to help individuals communicate more effectively and assert their needs and rights while respecting others. However, for someone with narcissistic personality disorder (NPD), this approach may not address the core issues of grandiosity and lack of empathy.

Choice B reason: Response prevention therapy is often used in the treatment of obsessive-compulsive disorder to help prevent the individual from engaging in compulsive behaviors. It is not typically indicated for NPD, as it does not address the underlying issues of self-esteem and empathy.

Choice C reason: Schema-focused therapy is designed to help individuals with NPD by identifying and changing deeply ingrained patterns of thinking and behavior, known as schemas, that are often maladaptive. This therapy can help address the root causes of NPD, such as feelings of inadequacy and the need for admiration, making it a suitable recommendation for someone with NPD³.

Choice D reason: Cognitive behavioral therapy (CBT) can be effective for a range of mental health disorders by helping individuals recognize and change negative thought patterns. While CBT can be beneficial for someone with NPD, schema-focused therapy is often preferred because it goes deeper into the personality structure and addresses the specific challenges of NPD³.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing laboratory results of a client who has schizophrenia and is taking risperidone. For which of the following findings should the nurse notify the provider?

Correct Answer is A

Explanation

A nurse is caring for a client who has narcissistic personality disorder. Which of the following treatments should the nurse recommend?

Correct Answer is C

Explanation

A nurse is caring for a client who has social anxiety disorder. The client reports experiencing feelings of anxiousness that disrupt their sleep. Which of the following recommendations should the nurse make?

A nurse is planning overall strategies to address problems for a client who has borderline personality disorder. Which of the following strategies is the priority for the nurse to incorporate in the plan of care?

A nurse is visiting with the partner of a client who recently died. The partner expresses guilt that they did not do more for their partner. Which of the following responses should the nurse make?

A nurse is creating a plan of care for a client who has schizophrenia and is experiencing command hallucinations. Which of the following interventions should the nurse include in the plan?

A nurse is caring for a client who has a depressive disorder. The client states, "I don't always go to bed at night, so I get in trouble for falling asleep at work." Which of the following interventions should the nurse recommend?

A nurse is planning care for a client who has complicated grieving following the death of their child. Which of the following interventions should the nurse identify as the priority?

A nurse in a rehabilitation center is caring for a client who has bipolar disorder. Which of the following actions by the client indicates mania?

A nurse is caring for a client who begins yelling and pacing around the room. Which of the following actions should the nurse take? (Select all that apply.)