The nurse is preparing to document information obtained from a client diagnosed with a delusional disorder who is experiencing somatic delusions. Which of the following would the nurse most likely document?

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Question 1 of 9

The nurse is preparing to document information obtained from a client diagnosed with a delusional disorder who is experiencing somatic delusions. Which of the following would the nurse most likely document?

Correct Answer: D

Rationale: The correct answer is D: Body complaints. Somatic delusions involve false beliefs about one's body, such as having a serious illness or physical defect. The nurse would document the client's body complaints as they are directly related to the somatic delusions. Disorientation (A) and reduced attention span (B) are not specific to somatic delusions. Above average intelligence (C) is unrelated to the client's delusional disorder.

Question 2 of 9

April, a 10-year-old admitted to inpatient pediatric care, has been getting more and more wound up and is losing self-control in the day room. Time-out does not appear to be an effective tool for April to engage in self-reflection. April's mother admits to putting her in time-out up to 20 times a day. The nurse recognizes that:

Correct Answer: B

Rationale: The correct answer is B because the scenario indicates that time-out is no longer effective for April. The fact that April's mother puts her in time-out up to 20 times a day suggests overuse, leading to desensitization. This renders time-out ineffective as a therapeutic tool. April's increasing agitation and lack of self-control despite time-outs indicate the need for a different approach. Choices A and C are incorrect because they assume time-out is still effective, which contradicts the scenario. Choice D is incorrect as seclusion and restraint should only be considered as a last resort due to ethical and safety concerns.

Question 3 of 9

A nurse is working with a child for which an out-of-home placement has occurred. Which of the following would the nurse anticipate as the child's initial response?

Correct Answer: C

Rationale: The correct answer is C: Protest. When a child experiences an out-of-home placement, they typically respond with protest initially, displaying anger, resistance, and a sense of loss. This is a common reaction as the child may feel abandoned or confused. Despair (A) is usually a later response after protest. Withdrawal (B) involves isolating oneself, which is not an immediate response to out-of-home placement. Detachment (D) is a form of emotional disengagement, which is also not typically the initial response in this situation.

Question 4 of 9

A patient's 5-year-old poodle ran in front of a car and was killed. The patient continues to be upset by her pet's death, and she explains to a community counseling center nurse that she can't stop crying because, 'My Precious meant the world to me, and now my world will never be the same!' If the nurse were to determine that the patient was experiencing a crisis, which of the following types of crisis would it most likely be?

Correct Answer: B

Rationale: The correct answer is B: Situational crisis. In this scenario, the patient's overwhelming emotional response to her pet's death is due to a specific, unexpected event - the loss of her beloved pet. Situational crises are triggered by external events that disrupt an individual's normal functioning. The patient's distress is directly linked to the situation at hand, which is the sudden death of her poodle. Choice A: Maturational crisis, involves normal life transitions or stages. The patient's response is not related to a typical life event but to a specific incident. Choice C: Traumatic crisis, typically involves a life-threatening or deeply disturbing event. While the loss of a pet can be traumatic, in this case, the patient's distress seems more related to the emotional bond with her pet rather than the traumatic nature of the event. Choice D: Developmental crisis, occurs when an individual struggles to achieve a new developmental stage. The patient's grief is not related to a failure

Question 5 of 9

When describing the influence of Harry Stack Sullivan on psychiatric-mental health nursing, which of the following would the instructor address as a major concept?

Correct Answer: A

Rationale: The correct answer is A: Interpersonal relations. Harry Stack Sullivan is known for his focus on interpersonal relations as a major concept in psychiatric-mental health nursing. Sullivan emphasized the importance of understanding and improving relationships between individuals as a key factor in mental health. He believed that a person's development and well-being are greatly influenced by their interactions with others. This concept is fundamental in psychiatric nursing practice as it guides therapeutic communication and relationship-building with patients. Choices B, C, and D are incorrect because they do not directly align with Sullivan's emphasis on interpersonal relations in the context of psychiatric-mental health nursing.

Question 6 of 9

A group of nursing students are reviewing information related to drug therapy for mood disorders. The students demonstrate understanding of the information when they identify which agent as the gold standard for treating bipolar disorder?

Correct Answer: B

Rationale: The correct answer is B: Lithium. Lithium is considered the gold standard for treating bipolar disorder due to its proven efficacy in reducing manic episodes and preventing relapse. It has been used for decades and has a well-established track record. Additionally, lithium has a unique mechanism of action in stabilizing mood by modulating neurotransmitters. Carbamazepine, valproate, and lamotrigine are also used in treating bipolar disorder, but they are not considered the gold standard like lithium. Carbamazepine and valproate are typically used as alternative options or in combination with other medications, while lamotrigine is often used for bipolar depression rather than mania.

Question 7 of 9

The nurse makes a home visit to a family caring for a client with Alzheimer's disease. The client's wife tells the nurse that she hasn't been out of the house for more than 2 weeks because her sister has been unable to help her care for the client. Which nursing diagnosis would the nurse identify as the priority?

Correct Answer: C

Rationale: The correct answer is C: Caregiver Role Strain related to social isolation. The priority nursing diagnosis addresses the wife's current state of distress due to social isolation, which can impact her ability to provide care for the client. This diagnosis directly addresses her feelings of being overwhelmed and unable to fulfill her caregiving role effectively. In contrast, option A focuses on family coping, which is secondary to the wife's immediate need for support. Option B is not as relevant since it does not address the wife's emotional and psychological stress. Option D refers to the client's emotional state rather than the wife's, making it less of a priority in this scenario.

Question 8 of 9

Walking down the aisle of a local grocery store, a nurse encounters a client the nurse has recently cared for on an inpatient psychiatric setting. Which is the appropriate reaction by the nurse?

Correct Answer: D

Rationale: The correct answer is D because making eye contact and responding if the client engages maintains professionalism and acknowledges the client's presence without compromising confidentiality. It shows respect and empathy, which are important in nursing practice. A: Inquiring about the client's well-being can breach confidentiality and may not be appropriate in a public setting. B: Ignoring the client can be seen as rude and may harm the therapeutic relationship. C: Talking to the client without using names may still breach confidentiality and does not fully acknowledge the client's presence.

Question 9 of 9

What is an example of an adjunctive treatment in mental health care?

Correct Answer: D

Rationale: The correct answer is D: yoga. Adjunctive treatments are used alongside primary treatments to enhance outcomes. Yoga is a complementary therapy that can improve mental health by reducing stress, anxiety, and improving overall well-being. It is non-invasive and can be used in conjunction with other treatments like psychotherapy. Antipsychotic medication (A) is a primary treatment for certain mental health conditions like schizophrenia. Hospitalization (B) is a severe intervention for acute mental health crises. Psychotherapy (C) is a primary treatment involving talk therapy. Yoga (D) stands out as an adjunctive treatment due to its holistic approach and ability to support mental health alongside other therapies.

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