The nurse is observing the interaction between a mother and schizophrenic son. The son states, "The man visiting me said you went on vacation without me." The mother replied, "There is no man, you are just making that up." When interacting with the mother privately, which reply from the mother would the nurse suggest?

"I am not on vacation. I am here with you."

"How can I go on vacation. I do not have any money."

"Stop saying that. You know better. No one told you that."

"Just forget about that and let's talk about something else."

Answer and Explanation

The Correct Answer is A

A. "I am not on vacation. I am here with you." This response calmly reassures the client by affirming the mother’s presence, which helps address the son’s confusion without directly challenging his perception.

B. "How can I go on vacation? I do not have any money." This response could increase confusion and does not address the son's needs effectively. It could also lead to unnecessary discussions that might not be helpful.

C. "Stop saying that. You know better. No one told you that." This response is dismissive and confrontational, which may exacerbate the son’s distress and could damage the therapeutic relationship.

D. "Just forget about that and let's talk about something else." This response avoids addressing the son’s concerns, which can make him feel dismissed and not listened to, potentially worsening his symptoms.

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Correct Answer is B

Explanation

A. "I wouldn't tell if I were you." This response is inappropriate because it imposes the nurse's personal opinion rather than supporting the family in making an informed decision.

B. "In my experience, clients who know are more likely to be involved with their plan of care." This is the best response because it encourages transparency and patient autonomy, allowing the client to participate in their care decisions.

C. "The shock of learning the diagnosis may be too much stress for an elderly person.” This response is not based on evidence and may discourage the family from being honest with the client, which could prevent the client from making informed decisions.

D. "This is a private concern that should include the physician, not me." While the physician should be involved in the discussion, the nurse also plays a crucial role in providing support and guidance to the family. This response dismisses the nurse's role in the situation.

A. Pharmacotherapy B. Client safety C. Cognitive-behavioral therapy D. Distraction therapy

Correct Answer is B

Explanation

A. Pharmacotherapy: While medication is crucial in managing bipolar disorder, the immediate priority during a manic episode is ensuring the client's safety, as they may engage in risky behavior.

B. Client safety: Client safety is the highest priority during a manic episode, as clients may act impulsively, which can lead to harm to themselves or others.

C. Cognitive-behavioral therapy: CBT is an important therapeutic intervention for long-term management, but it is not the immediate priority during a manic episode.

D. Distraction therapy: Distraction techniques can be helpful, but they are not a priority compared to ensuring the client’s safety.

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Naxlex Comprehensive Predictor Exams

An elderly client has been diagnosed with metastatic cancer and has a poor prognosis of survival. The family asks the nurse for advice on whether to tell the client of the diagnosis or to keep it quiet. Which is the best response from the nurse?

Correct Answer is B

Explanation

A client who suffers from bipolar disorder is admitted to a mental health unit for a manic episode. The nurse knows that which takes priority?

Correct Answer is B

Explanation

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A client enters the emergency room exhibiting tremors, agitation, and restlessness. Upon assessment, the client's blood pressure is 160/90, pulse is 110, and respirations are 22. It has been 36 hours since the client's last drink of alcohol. The nurse would suspect which conditions to be occurring?

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