ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 72 : Caring for Clients With Dementia and Thought Disorders Questions
Question 1 of 5
The nurse is caring for a client who states: 'Can you tell this man sitting on the chair to leave my room. I am tired of him watching me.' The nurse notes that there is no one else in the room. The nurse would document the client's experience as which of the following?
Correct Answer: C
Rationale: The nurse is correct to document the client's experience of a man in the room as a hallucination. Hallucinations are sensory experiences only the client perceives. They are auditory or visual in nature. A delusion is characterized by a disturbed thinking process. Dementia is the disturbance or decline in memory. Delirium is a sudden state of confusion.
Question 2 of 5
The nurse is discharging four clients from the behavioral health unit. Which client would be the best candidate for long-term inpatient care?
Correct Answer: D
Rationale: Once a client is in the mental health system, every effort is made to avoid institutionalization. The exception is when the client is dangerous to self and others. The nurse is most correct to anticipate the client with suspicion and anger to be the best candidate for long-term inpatient care. Clients who have hallucinations or feelings of persecution and those with a love interest being discharged from a behavioral health unit can be monitored in an outpatient setting.
Question 3 of 5
The nurse is caring for a client who has experienced readmission to the behavioral health unit for an exacerbation of schizophrenia. Which assessment question asked by the nurse identifies a possible cause for the return?
Correct Answer: B
Rationale: The nurse is correct to identify that noncompliance with drug therapy is the leading cause of the return of disease symptoms and the need for short-term hospitalization. Asking when the client's last dose of medication was opens communication for when the medication was last administered. If it was not at the prescribed time, the conversation allows the nurse to probe why. Taking a generic medication does not change the effectiveness. Asking if the client can afford the medication or if the medication causes side effects does not directly address the question of noncompliance.
Question 4 of 5
During a multidisciplinary meeting, the group discussed potential signs of tardive dyskinesia noted sporadically in a client. Following the meeting, symptoms progressed for the client. Which medical order does the nurse anticipate?
Correct Answer: B
Rationale: Nurses and the multidisciplinary team consistently assess the client taking antipsychotic medications to check for tardive dyskinesia. When symptoms progress, the nurse should report the symptoms immediately because the drug must be discontinued. Reducing the dose, adjunct medications, and alternative treatments would not be the medical orders issued.
Question 5 of 5
The nurse is observing the interaction between a parent and child with schizophrenia. The child states, 'The man visiting me said you went on vacation without me.' The parent replies 'There is no man, you are just making that up.' When interacting with the parent privately, which reply from the parent would the nurse suggest?
Correct Answer: A
Rationale: The nurse is correct to suggest not arguing with the client. This can escalate the situation. The nurse should suggest not validating the delusional belief and focus the discussion to the 'here and now.'