On review of the client’s record, the nurse notes that the admission was voluntary. Based on this information, the nurse plans care anticipating which client behavior?

Anger and aggressiveness directed toward others

Fearfulness regarding treatment measures

Willingness to participate in the planning of the care and treatment plan

An understanding of the pathology and symptoms of the diagnosis

Answer and Explanation

The Correct Answer is C

Choice A reason:
Anger and aggressiveness directed toward others are not typically associated with voluntary admission. Clients who voluntarily seek treatment are usually motivated to improve their condition and are less likely to exhibit aggressive behaviors towards others. Aggressiveness may be more common in involuntary admissions where the client feels coerced.

Choice B reason:
Fearfulness regarding treatment measures can occur in any client, regardless of whether the admission is voluntary or involuntary. However, clients who voluntarily admit themselves are generally more open to treatment and less likely to exhibit significant fearfulness about the treatment process.

Choice C reason:
Willingness to participate in the planning of the care and treatment plan is a common behavior in clients who have voluntarily admitted themselves. These clients are typically motivated to engage in their treatment and collaborate with healthcare providers to achieve their health goals. Voluntary admission often indicates a proactive approach to managing their condition.

Choice D reason:
An understanding of the pathology and symptoms of the diagnosis is not necessarily linked to the nature of the admission. While some clients may have a good understanding of their condition, others may not, regardless of whether their admission was voluntary or involuntary. Education about the diagnosis is an important part of the treatment process for all clients.

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Correct Answer is D

Explanation

Choice A reason:
The statement “I think that the federal government is spying on me” reflects a delusional belief, which is a symptom of certain mental health disorders. While this statement indicates the need for further assessment and possibly treatment, it does not pose an immediate threat to the safety of the client or others. Therefore, it does not warrant breaching confidentiality.

Choice B reason:
Expressing anger towards a doctor, as in the statement “That doctor I had today really made me angry,” is not uncommon in a mental health setting. While it may indicate dissatisfaction or a need for conflict resolution, it does not suggest an immediate risk of harm to the client or others. Confidentiality should be maintained unless there is a clear and imminent threat.

Choice C reason:
The statement “I get really ‘turned on’ by your appearance” is inappropriate and may indicate boundary issues or sexual attraction towards the nurse. While this requires professional handling and possibly setting boundaries, it does not constitute a threat that would necessitate breaching confidentiality.

Choice D reason:
The statement “When I get out of here, I’m going to make my neighbor sorry” indicates a specific threat of harm towards another person. Nurses are legally and ethically obligated to breach confidentiality in situations where there is a clear and imminent risk of harm to the client or others. This duty to warn and protect overrides the obligation to maintain confidentiality.

A. Assign an assistive personnel to feed the client at mealtimes. B. Use touch to calm the client during periods of anxiety. C. Rotate staff assignments for this client. D. Check the client’s mouth after the client takes medication.

Correct Answer is D

Explanation

Choice A reason:
Assigning assistive personnel to feed the client at mealtimes is not typically necessary for clients with paranoid schizophrenia unless there are specific physical limitations. This intervention does not address the unique needs of managing paranoia and ensuring medication adherence.

Choice B reason:
Using touch to calm the client during periods of anxiety is not recommended for clients with paranoid schizophrenia. These clients may misinterpret touch as a threat, exacerbating their paranoia and anxiety.

Choice C reason:
Rotating staff assignments for this client can increase anxiety and paranoia. Consistency in caregivers helps build trust and reduces the client’s suspicion and anxiety.

Choice D reason:
Checking the client’s mouth after the client takes medication is crucial to ensure that the client has swallowed the medication. Clients with paranoid schizophrenia may hide or refuse medication due to their distrust, so this intervention helps ensure they receive their prescribed treatment.

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On review of the client’s record, the nurse notes that the admission was voluntary. Based on this information, the nurse plans care anticipating which client behavior?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is hospitalized for a mental disorder. The nurse is legally obligated to breach the client’s confidentiality if the client makes which statement?

Correct Answer is D

Explanation

A nurse is planning care for a client who has paranoid schizophrenia. Which of the following interventions should be included in the plan of care?

Correct Answer is D

Explanation

When engaged in therapeutic communication with a client who has been diagnosed with a mental disorder, which is the most important principle for a nurse to keep in mind?

A nurse is explaining advance care directives, or “living wills,” to a client and the client’s spouse. Which detail would the nurse include in the description of an advance care directive?

A nurse is providing education to a group of staff members about schizophrenia. Which of the following age groups should the nurse include as the age when schizophrenia is typically diagnosed?

While working with an older client, a nurse begins to think of the client as a grandparent and responds to the client as a grandchild. The nurse is developing what type of emotional reaction?

The charge nurse is talking with another nurse who states, “I feel like my clients have no interest in their care and do not care that I am trying to help.” Which response should the charge nurse make?

A nurse is caring for a client who is experiencing a crisis related to anxiety. Which of the following actions should the nurse take? (Select all that apply).

A nurse manager is discussing suicide with nursing staff. Which of the following should the manager identify as risk factors for suicide? (Select all that apply)