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. Hypotension: Hypotension is typically associated with decreased preload and low PAWP rather than elevated values. An elevated PAWP reflects increased pressure in the left heart, which does not occur with simple hypotension alone.
B. Hypovolemia: Hypovolemia leads to decreased circulating blood volume, reducing preload and PAWP. It is typically marked by low filling pressures, not elevated wedge pressures.
C. Cardiogenic shock: Although cardiogenic shock can be associated with elevated PAWP due to poor cardiac output and fluid backup, it is not as specific a marker as left ventricular failure, which directly affects PAWP.
D. Left ventricular failure: Elevated PAWP reflects increased pressure in the left atrium and pulmonary circulation, which is a hallmark of left-sided heart failure. This elevation occurs because the failing left ventricle cannot efficiently pump blood forward.
Correct Answer is D
Explanation
Rationale:
A. The nurse explained the risks and benefits of the surgery: Explaining the risks and benefits of a surgical procedure is the responsibility of the surgeon, not the nurse. The nurse may clarify or reinforce information but does not provide the primary explanation.
B. The nurse explained the surgical procedure in detail: Nurses can offer general clarification, but it is the surgeon’s legal and ethical duty to explain the procedure in detail, including alternatives, risks, and benefits, as part of obtaining informed consent.
C. The client knows they may no longer refuse the procedure: Clients have the legal right to refuse a procedure at any time, even after signing consent. Consent is not binding and must remain voluntary and revocable until the procedure begins.
D. The client agreed to the procedure voluntarily: Informed consent requires that the client makes the decision freely, without coercion. Observing the client voluntarily agree to the procedure meets this core legal and ethical requirement of informed consent.
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