A patient diagnosed with schizophrenia tells the nurse, "The CIA is monitoring us through the fluorescent lights in this room. Be careful what you say." Which response by the nurse would be most therapeutic?

"It sounds like you’re concerned about your privacy."

"The CIA is prohibited from operating in health care facilities."

"Let’s talk about something other than the CIA."

"You have lost touch with reality, which is a symptom of your illness."

Answer and Explanation

The Correct Answer is A

Choice A reason: This response acknowledges the patient’s feelings without confirming or denying the delusion. It helps establish trust while maintaining therapeutic communication. By focusing on the patient’s underlying concern, it avoids reinforcing the delusional content.

Choice B reason: Stating that the CIA is prohibited in health care facilities engages with the delusion, which is non-therapeutic because it validates the false belief.

Choice C reason: Redirecting away from the delusion may seem dismissive and does not address the patient’s immediate feelings of fear or concern. This could cause the patient to feel unheard.

Choice D reason: Telling the patient they have “lost touch with reality” is confrontational and could increase defensiveness. It is not supportive or therapeutic in building rapport.

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Correct Answer is C

Explanation

Choice A reason: These traits are characteristic of dependent personality disorder, where clients fear separation and rely heavily on others for decision-making and support.

Choice B reason: This describes schizoid personality disorder, in which individuals show detachment from relationships and emotional indifference.

Choice C reason: Histrionic personality disorder is marked by attention-seeking, dramatic and exaggerated emotions, and difficulty coping with delayed gratification, making this the correct description.

Choice D reason: These are traits of antisocial personality disorder, which involves manipulation, intimidation, and lack of empathy.

A. Avoid foods high in tyramine, such as aged cheeses, smoked meats, and fermented products. B. Use over-the-counter cold medications containing pseudoephedrine cautiously. C. Take the medication with food to minimize gastrointestinal upset. D. Avoid driving or operating heavy machinery until the effects are known.

Correct Answer is A

Explanation

Choice A reason: The most critical teaching with MAOIs is to avoid foods containing tyramine. Eating these foods can trigger a hypertensive crisis, a potentially fatal complication.

Choice B reason: Cold medications with pseudoephedrine may also increase blood pressure and should be avoided, but dietary restrictions are more essential because food exposure is more common and life-threatening if overlooked.

Choice C reason: Taking the medication with food may reduce mild gastrointestinal side effects, but this is not the priority safety teaching.

Choice D reason: Avoiding hazardous activities until medication effects are known is general advice for many psychotropic drugs, but it is not specific or lifesaving for MAOI therapy.

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A patient diagnosed with schizophrenia tells the nurse, "The CIA is monitoring us through the fluorescent lights in this room. Be careful what you say." Which response by the nurse would be most therapeutic?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse assigned to care for the client with a diagnosis of histrionic personality disorder expects to observe which characteristics and behaviors?

Correct Answer is C

Explanation

A nurse is educating a client who has been prescribed phenelzine, an MAOI, for treatment-resistant depression. Which of the following instructions is most critical to prevent potentially life-threatening complications associated with this medication?

Correct Answer is A

Explanation

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