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. Limit teaching sessions about the procedure to 20 min: Preschoolers have short attention spans, but 20 minutes is still too long for teaching at this developmental stage. Teaching should be concise and focused, ideally lasting only a few minutes just before the procedure.
B. Explain in simple terms how the procedure will affect the child: Preschoolers benefit from clear, age-appropriate explanations that help them understand what to expect. Using simple language and concrete terms reduces fear and builds trust with the nurse.
C. Ask the parents to wait outside the room during the procedure: Parents often provide comfort and reassurance during stressful experiences. Unless they are interfering or the child requests otherwise, their presence can help reduce the child’s anxiety.
D. Instruct the child in deep-breathing methods prior to the procedure: While relaxation techniques are helpful for older children, preschoolers may have difficulty understanding and following deep-breathing instructions. Simple distraction methods are often more effective.
Correct Answer is D
Explanation
Rationale:
A. “Dehydration is treated with calcium supplements.": Calcium supplementation is not a standard treatment for dehydration. Dehydration is primarily managed with fluid replacement, either orally or intravenously, depending on severity.
B. "Dehydration is caused by a decreased hemoglobin and hematocrit.": Dehydration often causes increased hemoglobin and hematocrit levels due to hemoconcentration, not a decrease. These lab values are used to assess hydration status but do not cause dehydration.
C. "Dehydration is associated with gastroesophageal reflux”: GERD is not a direct cause or result of dehydration. While fluid intake can influence GI symptoms, GERD and dehydration are unrelated conditions with different pathophysiologies.
D. "Dehydration can increase the risk for preterm labor”: Dehydration can trigger the release of antidiuretic hormone and oxytocin, both of which may lead to uterine contractions. It is a recognized risk factor for preterm labor and should be addressed promptly.
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