Nursing Elites

1. A female client with schizophrenia tells the nurse that she believes her brain is controlled by the CIA. The nurse recognizes this as which type of delusion?

• A. Somatic delusion
• B. Paranoid delusion
• C. Persecutory delusion
• D. Grandiose delusion

Correct answer: C

Rationale: The correct answer is C: Persecutory delusion. Persecutory delusions involve beliefs of being conspired against, watched, or harassed by others, which is a common symptom in schizophrenia. In this scenario, the client's belief that her brain is controlled by the CIA aligns with persecutory delusions as she feels targeted or manipulated by an external entity. Choices A, B, and D are incorrect. Somatic delusions involve false beliefs about one's body functions or sensations, paranoid delusions involve irrational suspicions and mistrust of others, and grandiose delusions involve exaggerated beliefs of one's importance or abilities.

2. The nurse is leading a 'current events group' with chronic psychiatric clients. One group member states, 'Clara Barton was my nurse during my last hospitalization. She was a very mean nurse and wasn't nice to me.' Which response would be best for the nurse to make?

• A. 'Clara Barton was not your nurse.'
• B. 'What did she do to you that was so mean?'
• C. 'I didn't know that Clara Barton was a nurse.'
• D. 'Clara Barton started the American Red Cross.'

Correct answer: D

Rationale: (D) presents the reality of the situation in relation to American culture. The fact that Clara Barton was a nurse during the Civil War should be addressed on an individual basis. Since this is group therapy, the nurse would be illustrating the concept of universality. (A) is likely to promote defensiveness. (B and C) would support the delusion. Therefore, the most appropriate response is (D) as it provides factual information that can redirect the conversation in a constructive manner.

3. A client with depression is started on a selective serotonin reuptake inhibitor (SSRI). The client asks, 'How long will it take for this medication to work?' What is the best response by the nurse?

• A. It may take 2 to 4 weeks before you start feeling better.
• B. You should start feeling better within a few days.
• C. The medication works immediately to improve your mood.
• D. It may take up to 8 weeks for the medication to take full effect.

Correct answer: D

Rationale: Explaining that it may take up to 8 weeks for the medication to take full effect provides the client with a realistic expectation. SSRI medications typically require time to build up in the body and exert their therapeutic effects. Choice A is incorrect as it underestimates the time frame required for the medication to work. Choice B is incorrect as SSRIs do not produce immediate effects. Choice C is incorrect as it falsely states that the medication works immediately, which is not true for SSRIs.

4. A client with generalized anxiety disorder is being taught about buspirone (BuSpar) by a nurse. Which statement by the client indicates a need for further teaching?

• A. I should take this medication on an empty stomach.
• B. It may take several weeks before I feel better.
• C. This medication does not cause dependence.
• D. I can drink alcohol while taking this medication.

Correct answer: D

Rationale: The statement 'I can drink alcohol while taking this medication' (D) indicates a need for further teaching. Clients should avoid alcohol while taking buspirone because it can increase the risk of side effects such as dizziness and drowsiness. Choices A, B, and C are correct statements regarding buspirone and do not require further teaching.

5. A young adult male client, diagnosed with paranoid schizophrenia, believes that the world is trying to poison him. What intervention should the nurse include in this client's plan of care?

• A. Remind the client that his suspicions are not true.
• B. Ask one nurse to spend time with the client daily.
• C. Encourage the client to participate in group activities.
• D. Assign the client to a room closest to the activity room.

Correct answer: B

Rationale: A client with paranoid schizophrenia has difficulty with trust and developing a trusting relationship with one nurse (B) is likely to be therapeutic for this client. Choice (A) is argumentative and may increase the client's resistance. Choice (C) might be too overwhelming and anxiety-provoking for the client. Choice (D) could increase the client's stress and anxiety, which are counterproductive in managing paranoid ideations.

Similar Questions