A 16-year-old-client diagnosed with paranoid schizophrenia experiences command hallucinations to harm others. The client's parents ask a nurse, "Where do the voices come from?" Which is the appropriate nursing reply?

Correct Answer: A

Rationale: The correct answer is A. The nurse should explain that paranoid schizophrenia is a mental illness caused by a chemical imbalance in the brain, leading to altered thoughts and perceptions, including hallucinations. This response educates the parents about the underlying cause of their child's symptoms. Rationale: A: Correct - Paranoid schizophrenia is caused by a chemical imbalance in the brain, resulting in altered thoughts and perceptions. B: Incorrect - Hallucinations in schizophrenia are not typically caused by medication interactions. C: Incorrect - While serotonin levels may play a role in mental health, low serotonin alone does not directly cause schizophrenia hallucinations. D: Incorrect - Hormonal changes are not the primary cause of auditory hallucinations in paranoid schizophrenia.

Correct Answer: C

Rationale: The correct answer is C: Rationalization. The patient is justifying or making excuses for his behavior of throwing the lunch tray by complaining about the quality of the food. This defense mechanism allows him to avoid taking responsibility for his actions by attributing them to external factors. Denial (A) would involve refusing to acknowledge his behavior, displacement (B) would be redirecting his emotions to a different target, and repression (D) would involve unconsciously blocking out the memory of his behavior. In this scenario, rationalization best fits as the patient is attempting to make his actions seem reasonable or justified.

Correct Answer: D

Rationale: The correct answer is D: Masked grief. Masked grief refers to expressing grief through behaviors that may not seem related, such as engaging in reckless or promiscuous behaviors. In this case, the woman's promiscuity is masking her underlying grief over her fiancé's death. This type of grief can be challenging to identify because the connection between the behavior and the grief is not obvious. A: Anticipatory grief occurs before a loss, such as when someone is terminally ill. B: Chronic grief is when the individual experiences ongoing, long-term grief. C: Exaggerated grief involves an intense, prolonged reaction to a loss, which is not evident in this scenario.

Correct Answer: B

Rationale: The correct answer is B: Call the HCP to discuss the order. This is the best course of action because it allows the nurse to clarify the order directly with the healthcare provider. By communicating with the HCP, the nurse can ensure patient safety by confirming the correct dosage and potentially prevent medication errors. Informing the nursing supervisor (Choice A) may be necessary but should not be the first step. Giving the drug as ordered (Choice C) poses a risk if the dose is indeed too high. Giving the standard dose (Choice D) without clarification may not align with the HCP's intention. Communication with the HCP is essential for patient safety and adherence to proper protocols.

Correct Answer: A

Rationale: The correct answer is A: Cardiac. When a client presents with chest pain, the nurse should address the cardiac area first because it is essential to rule out potentially life-threatening conditions like a heart attack. The heart is a vital organ, and any issues related to it require immediate attention. Respiratory issues could also cause chest pain, but cardiac concerns must be prioritized due to their severity. Gastrointestinal and musculoskeletal causes of chest pain are typically less urgent and can be considered after cardiac concerns have been addressed.