The nurse is completing an admission assessment of a client who is admitted to milieu. Which piece of information obtained from the client during the assessment would require immediate investigation from the nurse regarding the client’s use of complementary and alternative therapies?

Uses relaxation techniques for stress reduction.

Expresses an interest in yoga to improve flexibility.

Has tried acupressure for pain relief several years ago.

Has been using herbal supplements without consulting a healthcare provider.

Answer and Explanation

The Correct Answer is D

Choice A Reason:

Uses relaxation techniques for stress reduction.

Using relaxation techniques for stress reduction is generally considered safe and beneficial. Techniques such as deep breathing, meditation, and progressive muscle relaxation can help reduce stress and anxiety without significant risks. Therefore, this information does not require immediate investigation.

Choice B Reason:

Expresses an interest in yoga to improve flexibility.

Expressing an interest in yoga to improve flexibility is also generally safe and beneficial. Yoga can enhance physical flexibility, strength, and mental well-being. Unless the client has specific health conditions that might be affected by certain yoga poses, this information does not require immediate investigation.

Choice C Reason:

Has tried acupressure for pain relief several years ago.

Trying acupressure for pain relief several years ago is not typically a cause for concern. Acupressure is a non-invasive therapy that can help alleviate pain and promote relaxation. Since it was used in the past and not currently, it does not require immediate investigation.

Choice D Reason:

Has been using herbal supplements without consulting a healthcare provider.

This is the correct response. Using herbal supplements without consulting a healthcare provider can be risky because some supplements can interact with prescribed medications or have side effects. It is crucial for the nurse to investigate this information immediately to ensure the client’s safety and prevent potential adverse effects.

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Correct Answer is D

Explanation

Choice A Reason:

“There is no such thing as the devil. It’s all in your mind.”

This response dismisses the client’s experience and can make them feel invalidated. Telling the client that their experience is “all in your mind” does not acknowledge their distress and can increase their feelings of isolation and mistrust. It is important to validate the client’s feelings while gently orienting them to reality.

Choice B Reason:

“You are not going to hell. You are a good person.”

While this response is supportive, it does not address the client’s immediate distress about hearing voices. It is important to acknowledge the client’s experience of hearing voices and provide reassurance in a way that helps them feel understood and supported. Simply telling them they are a good person may not alleviate their anxiety about the voices.

Choice C Reason:

“Did you take your medicine this morning?”

Asking about medication adherence is important, but it is not the most appropriate immediate response to the client’s distress. This question can come across as dismissive and may not provide the immediate comfort and validation the client needs. It is better to first acknowledge the client’s experience and then address medication adherence later.

Choice D Reason:

“The voices sound distressing, but I don’t hear them.”

This is the correct response. It acknowledges the client’s distress and validates their experience without reinforcing the delusion. By stating that the nurse does not hear the voices, it gently orients the client to reality while showing empathy and understanding. This approach helps build trust and provides comfort to the client.

A. Recommend the client distance themselves from people who knew them before their diagnosis. B. Provide the client with a multi-step written plan to follow if auditory hallucinations occur. C. Risperidone as a depot formulation every 2 weeks. D. Increase white bread and bananas to help with anticholinergic symptoms. E. Assist the client to enroll in a program of assertive community treatment.

Correct Answer is ["B","C","E"]

Explanation

Choice A Reason:

Recommending the client distance themselves from people who knew them before their diagnosis is not a suitable measure for tertiary prevention. Tertiary prevention aims to reduce the impact of an ongoing illness by helping patients manage long-term, complex health problems and injuries. It focuses on improving quality of life and reducing symptoms. Distancing from familiar people could lead to social isolation, which might worsen the client’s condition.

Choice B Reason:

Providing the client with a multi-step written plan to follow if auditory hallucinations occur is a practical measure for tertiary prevention. This plan can help the client manage symptoms effectively and reduce the likelihood of hospitalization. It empowers the client to take control of their symptoms and provides clear steps to follow during a crisis, which can be crucial for maintaining stability.

Choice C Reason:

Risperidone as a depot formulation every 2 weeks is an effective measure for ensuring medication adherence in clients with schizophrenia. Depot formulations are long-acting injections that help maintain consistent medication levels in the body, reducing the risk of relapse due to missed doses. This approach is particularly beneficial for clients who have difficulty adhering to daily oral medication regimens.

Choice D Reason:

Increasing white bread and bananas to help with anticholinergic symptoms is not a recommended measure for managing schizophrenia. While diet can play a role in overall health, there is no evidence to suggest that these specific foods help with anticholinergic symptoms. Anticholinergic symptoms are typically managed with medications and other medical interventions.

Choice E Reason:

Assisting the client to enroll in a program of assertive community treatment (ACT) is a highly effective measure for tertiary prevention. ACT provides comprehensive, community-based psychiatric treatment, rehabilitation, and support to individuals with serious and persistent mental illnesses. This approach helps clients manage their symptoms, adhere to treatment plans, and reduce the risk of hospitalization by providing continuous, personalized care.

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The nurse is completing an admission assessment of a client who is admitted to milieu. Which piece of information obtained from the client during the assessment would require immediate investigation from the nurse regarding the client’s use of complementary and alternative therapies?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with schizophrenia approaches the nurse with a look of distress and anguish on his face. He says, “Can’t you hear him? It’s the devil. He’s telling me I’m going to hell.” Which is the most appropriate response by the nurse?

Correct Answer is D

Explanation

A client with schizophrenia has had 2 hospitalizations within the past 9 months due to non-adherence to medications and their counseling plan. What measures should the nurse and the mental health treatment team recommend for tertiary prevention? (Select All That Apply)

Correct Answer is ["B","C","E"]

Explanation

A 23-year-old is about to take a math test. A nursing assessment reveals mild anxiety. The nurse explains that this level of anxiety:

The nurse notices a client wandering in the hospital hall giggling, with bizarre behavior that is annoying and frightening other clients. A priority in caring for her is to:

A nurse notices that a client with paranoid schizophrenia stops in mid-sentence when talking and tilts his head to the side as if to listen. The most appropriate intervention by the nurse would be to:

A client is diagnosed with schizophrenia. The nurse would interpret which behavior as apathy? The client is:

A nurse is caring for a client who has schizophrenia and is experiencing command auditory hallucinations. Which of the following actions should the nurse take?

A client diagnosed with an Anxiety Disorder tells a nurse that being in crowds creates thoughts of losing control and the need to suddenly leave. What should the nurse recommend as an effective, non-pharmacological therapy for managing the client’s symptoms of anxiety?

A nurse would expect to administer which of the following medications to a client who is escalating to the point of a possible assault?

The nurse who has been caring for a client with generalized anxiety disorder (GAD) recognizes that care has been effective when the client is able to: (SELECT ALL THAT APPLY)