A nurse on an inpatient mental health unit is caring for a client.
Client's chief complaint
Client's job performance history
Client's relationships with family and friends
Client's copying nurses words
Client's statement about their mother
Client's speech pattern
Correct Answer : A,D,E,F
Rationale:
A. Client's chief complaint: Hearing voices is an auditory hallucination, which is a hallmark positive symptom of schizophrenia. Hallucinations reflect a distortion of reality and are typically responsive to antipsychotic treatment.
B. Client's job performance history: Poor job performance reflects functional decline, which is a negative symptom (e.g., avolition or anhedonia), not a positive one. It indicates loss of normal function rather than distortion.
C. Client's relationships with family and friends: Social withdrawal is another negative symptom, reflecting a lack of interest or emotional engagement. Positive symptoms are additions to normal experience, not losses like this.
D. Client's copying nurses' words: Repeating others’ words is known as echolalia, a disorganized thought manifestation commonly seen in schizophrenia. It indicates impaired cognitive processing and communication.
E. Client's statement about their mother: The delusional belief that their mother is trying to kill them represents a paranoid delusion, a classic positive symptom. Such fixed false beliefs are unrelated to reality and resistant to logic.
F. Client's speech pattern: Unclear, jumbled, and disorganized speech reflects disorganized thinking, another positive symptom of schizophrenia. This makes coherent communication and goal-directed behavior difficult.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Fibrocystic breast condition: This benign breast disorder does not interfere with the use of oral contraceptives. In fact, hormonal birth control may sometimes reduce breast pain and nodularity associated with this condition.
B. Hypertension: High blood pressure is a known contraindication for oral contraceptive use, especially if it is uncontrolled. Estrogen-containing contraceptives can further elevate blood pressure and increase the risk of cardiovascular events such as stroke or myocardial infarction.
C. Fibromyalgia: Fibromyalgia does not interact with oral contraceptives and is not a contraindication. While hormonal changes may influence pain perception, there is no direct risk in using contraceptives for someone with this condition.
D. Asthma: Asthma is not a contraindication to using oral contraceptives. There is no evidence that hormonal contraceptives worsen asthma symptoms or interfere with its management.
Correct Answer is D
Explanation
Rationale:
A. Call in additional medical-surgical unit nursing care staff: The initial priority during a mass casualty event is to maximize available resources and free up beds by discharging stable clients. Staffing adjustments come after determining how to expand capacity.
B. Act as a liaison between the facility and the media: This role falls under the responsibilities of public relations or designated administrative personnel. Nurses should focus on patient care and operational tasks relevant to their scope during a crisis.
C. Determine the medical needs of incoming clients through the emergency department: Triage of incoming casualties is performed by designated emergency department staff. Nurses from other units typically assist by creating space or relocating stable clients.
D. Recommend to the provider specific acute care clients for discharge: Identifying stable clients who can be safely discharged allows beds and resources to be allocated to incoming critical cases. This is an appropriate and immediate nursing response during mass casualty.
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