ATI RN Custom NURS 120 Psychiatric Nursing FA23 Exam 2

Extract:

Question 1 of 5

A nurse is discussing schizophrenia spectrum disorders with a client. The client states, 'My friend says that before I started hearing voices, I stopped hanging out with them. Why is that?' Which of the following responses should the nurse make?

A. That is very interesting. We are not sure why people start to isolate themselves. B. Do you think of yourself as more of an introvert? That makes a difference with how you socialize. C. Before symptoms of schizophrenia begin, people often isolate themselves. This is an early warning. D. Were you avoiding your friend so that you could hear the voices more clearly?

Correct Answer: C

Rationale:
Correct
Answer: C

Rationale: Response C is the correct answer because it accurately explains that isolating oneself is often an early warning sign of schizophrenia spectrum disorders. This response demonstrates understanding of the relationship between social withdrawal and the onset of symptoms. It is essential for the nurse to educate the client about these early warning signs to facilitate early intervention and treatment.

Summary of other choices:
A: This response does not address the specific situation or provide relevant information about schizophrenia spectrum disorders.
B: This response focuses on introversion rather than the potential symptoms of schizophrenia spectrum disorders and does not address the client's concern.
D: This response makes an assumption about the client's behavior without providing accurate information about schizophrenia spectrum disorders.

Question 2 of 5

A nurse is caring for a client who was recently diagnosed with somatic symptom disorder. The client says to the nurse, 'I don't understand, they can't find anything medically wrong with me. I guess I will never feel better.' Which of the following responses is the most therapeutic?

A. Why do you feel like you will never get better? Do you not have confidence in the medical team? B. We will work with you to help you develop ways to manage your symptoms that are caused by the disorder. C. Let's focus on the physical symptoms that you have. D. Although there isn't a cure for this disorder, I am sure you will feel better someday.

Correct Answer: B

Rationale: Offering support to manage symptoms is therapeutic, addressing distress. Questioning confidence (
A), focusing on symptoms (
C), or vague reassurance (
D) is less helpful.

Question 3 of 5

A nurse in an acute mental health unit is admitting a client who has bipolar disorder. Which of the following findings supports the admitting diagnosis of acute mania?

A. The client's spouse reports that the client has recently gained weight. B. The client responds to questions with disorganized speech. C. The client reports that voices are telling him to write a novel. D. The client is dressed in all black.

Correct Answer: B

Rationale: Disorganized speech indicates acute mania, characterized by racing thoughts. Weight gain (
A), hallucinations (
C), and clothing choice (
D) are not specific to mania.

Question 4 of 5

A nurse is reviewing the medical record of a client who performs self-injury. Which of the following information should the nurse identify as placing the client at risk for self-harm behaviors?

A. The client has a history of bulimia nervosa. B. The client has a parent who has dependent personality disorder. C. The client has borderline personality disorder. D. The client recently received a promotion at work.

Correct Answer: C

Rationale: Borderline personality disorder is strongly linked to self-harm. Bulimia (
A) is less directly related, parental disorder (
B) is not a specific risk, and promotion (
D) is positive.

Question 5 of 5

A nurse is conducting an in-service for a group of newly licensed nurses about the interventions used for clients experiencing non-suicidal self-harm (NSSH). Which of the following should the nurse include?

A. Discourage clients from discussing the NSSH with friends. B. Early recognition is crucial to successful treatment. C. Recognize non-suicidal self-harm as an attention-seeking behavior. D. Ask the client why they do this as soon as possible.

Correct Answer: B

Rationale: Early recognition facilitates timely intervention for NSSH. Discouraging discussion (
A), labeling as attention-seeking (
C), and immediate questioning (
D) are unhelpful.

ATI RN Custom NURS 120 Psychiatric Nursing FA23 Exam 2 | Nurselytic

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