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 D
Explanation
Rationale:
A. "I will set a timer for 10 minutes for each timeout session.": Timeout duration should be age-appropriate, generally one minute per year of the child's age. A 10-minute timeout for a toddler would be too long and ineffective for promoting behavioral correction.
B. "My child will learn rules through physical punishment.": Physical punishment is not recommended for children as it may lead to increased aggression, fear, and long-term emotional harm. Positive discipline strategies like timeouts and redirection are more appropriate.
C. "I will remind my child of their misbehavior to reinforce discipline.": Repeated reminders can reinforce negative behavior by drawing excessive attention to it. Discipline should focus on clear, consistent consequences rather than prolonged discussion of misbehavior.
D. "A timeout session should begin once my child is quiet.": Timeout should start after the child calms down to encourage self-regulation. Starting it during a tantrum may reinforce the behavior, while waiting promotes emotional control and helps the child learn to calm themselves.
Correct Answer is A
Explanation
Rationale:
A. Use a powered lift to transfer the client: When a client is unable to assist and weighs significantly over standard lifting limits, a powered mechanical lift is the safest and most appropriate method. It reduces the risk of musculoskeletal injury to staff and ensures safe, controlled client movement.
B. Wrap their arms under the client's axilla to transfer the client: This manual lifting method can cause harm to both the nurse and the client. It increases the risk of shoulder injury for the client and back strain for the nurse, especially when the client is immobile and heavy.
C. Use a gait belt to transfer the client: Gait belts are used for clients who can bear some weight and assist in the transfer. Since this client cannot assist, a gait belt is insufficient and may result in injury or unsafe movement.
D. Use a sliding board to transfer the client: Sliding boards are typically used when clients have upper body strength and can assist in shifting their weight. For a fully dependent client of this size, it is not a safe or effective method without mechanical assistance.
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