Which assessment finding most clearly indicates that a patient may be experiencing a mental illness?

Reports occasional sleeplessness and anxiety

Cannot distinguish between "what is real" and "not real"

Expresses uncertainty about whether to change jobs

Reports sadness and low mood

Answer and Explanation

The Correct Answer is B

Choice A reason: Occasional sleeplessness and anxiety are common stress responses and do not necessarily indicate mental illness. These symptoms may reflect temporary issues rather than a diagnosable psychiatric condition, lacking specificity for severe mental illness compared to reality-testing deficits, making this choice incorrect.

Choice B reason: Inability to distinguish reality from non-reality is a hallmark of psychosis, a severe mental illness symptom seen in disorders like schizophrenia. This indicates impaired reality testing, a critical diagnostic criterion, making it the clearest indicator of mental illness among the options, thus the correct choice.

Choice C reason: Uncertainty about job changes reflects normal decision-making stress, not a mental illness. It lacks specificity for psychiatric conditions, as it is a common life concern. This choice does not indicate a significant mental health impairment compared to reality-testing issues, making it incorrect.

Choice D reason: Sadness and low mood may suggest depression, but they are less specific than psychotic symptoms like reality distortion. These feelings can occur in non-clinical contexts, making them less definitive for mental illness compared to inability to discern reality, rendering this choice incorrect.

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Correct Answer is C

Explanation

Choice A reason: Describing consequences of actions indicates cognitive awareness and problem-solving skills, but it does not directly reflect a healthy self-concept. Self-concept involves self-perception, esteem, and a balanced view of strengths and limitations. This choice focuses on behavioral outcomes, not internal self-worth, making it an inadequate indicator of the goal.

Choice B reason: Perceiving oneself as always capable of achieving goals suggests overconfidence or grandiosity, which can indicate a maladaptive self-concept, potentially linked to narcissistic traits. A healthy self-concept involves realistic self-assessment, acknowledging both strengths and limitations. This choice reflects an unbalanced view, making it incorrect for the goal of a healthy self-concept.

Choice C reason: Seeking help when needed demonstrates a healthy self-concept, reflecting self-awareness, humility, and confidence in recognizing personal limitations. This aligns with psychological theories of self-esteem, emphasizing balanced self-perception and social interdependence. It indicates emotional maturity and adaptive coping, making this the correct choice for achieving the goal.

Choice D reason: Meeting own needs without regard for others’ rights suggests selfishness or lack of empathy, indicative of a maladaptive self-concept. A healthy self-concept includes respect for social boundaries and reciprocity, which this choice violates. It reflects a self-centered approach, not a balanced or healthy self-perception, making it incorrect.

A. Monitor for weight gain and metabolic changes B. Watch for movement disorders like tardive dyskinesia C. Report any signs of infection immediately D. Expect improved mood within days

Correct Answer is B

Explanation

Choice A reason: Weight gain and metabolic changes are side effects of clozapine, primarily due to its antihistaminic and serotonergic effects, not its dopaminergic action. Dopamine blockade is more associated with movement disorders, making this choice incorrect for teaching related to dopaminergic effects.

Choice B reason: Clozapine’s strong dopaminergic effect, particularly D2 receptor blockade, can cause extrapyramidal symptoms like tardive dyskinesia, a movement disorder. Patient education must emphasize monitoring for abnormal movements, as these are significant risks in antipsychotic therapy, making this the correct choice.

Choice C reason: Infection risk, particularly agranulocytosis, is a serious clozapine side effect but is unrelated to its dopaminergic action. It stems from bone marrow suppression, requiring blood monitoring, not dopamine-related teaching, making this choice incorrect for the question’s focus.

Choice D reason: Improved mood is not a direct result of clozapine’s dopaminergic effect, which primarily addresses psychotic symptoms. Mood changes occur over weeks and involve multiple receptors, not just dopamine, making this choice incorrect for dopaminergic-focused teaching.

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Which assessment finding most clearly indicates that a patient may be experiencing a mental illness?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which finding best indicates that the goal "demonstrate a healthy self-concept" has been achieved for an adult?

Correct Answer is C

Explanation

A patient begins therapy with clozapine medication. What teaching should the nurse provide related to the drug’s strong dopaminergic effect?

Correct Answer is B

Explanation

An adult says, "I have no answers," and "My opinion does not count." Which psychosocial crisis was unsuccessfully resolved for this adult?

A nurse uses Maslow's hierarchy of needs to plan care for a patient diagnosed with mental illness. Which problem will receive priority?

A patient was hospitalized for 24 hours after a reaction to a psychotropic medication. While planning discharge, the nurse learned the patient received a notice of eviction immediately prior to admission. Select the nurse’s most appropriate action.

When using cognitive behavioral theory with an anxious, withdrawn patient, interventions should focus on which of the following?

The plan of care for a patient is not completed within 24 hours of the patient’s admission due to the unit being short-staffed. Which action should the nurse prioritize?

Which comment indicates the patient perceived the nurse was caring?

A patient has acute anxiety related to a car accident. The nurse knows the patient will need teaching about which medication category?

A fearful patient has an increased heart rate and blood pressure. The nurse suspects increased activity of which neurotransmitter?