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. A client with bipolar disorder is admitted to the psychiatric unit in a manic state. What is the most therapeutic nursing intervention?

• A. Allow the client to engage in any activity they choose.
• B. Provide a structured environment with reduced stimuli.
• C. Encourage the client to express their thoughts freely.
• D. Place the client in a room with another client for socialization.

Correct answer: B

Rationale: During a manic state, individuals with bipolar disorder may exhibit hyperactivity, impulsivity, and reduced need for sleep. Providing a structured environment with reduced stimuli is the most therapeutic nursing intervention as it can help manage the client's excessive energy and prevent overstimulation. Choice A is incorrect as allowing the client to engage in any activity they choose may exacerbate their symptoms or lead to risky behaviors. Choice C, encouraging the client to express their thoughts freely, may not be appropriate during a manic state as it can further escalate their racing thoughts. Choice D, placing the client in a room with another client for socialization, may not be beneficial during a manic episode as it could increase stimulation and potentially lead to agitation.

3. A male client approaches the nurse with an angry expression on his face and raises his voice, saying, 'My roommate is the most selfish, self-centered, angry person I have ever met. If he loses his temper one more time with me, I am going to punch him out!' The nurse recognizes that the client is using which defense mechanism?

• A. Denial
• B. Projection
• C. Rationalization
• D. Splitting

Correct answer: B

Rationale: The correct answer is B: Projection. In this scenario, the client is projecting his own feelings of anger and selfishness onto his roommate. Projection is a defense mechanism where individuals attribute their own unacceptable thoughts, feelings, and motives to another person. Choices A, C, and D are incorrect. Denial is refusing to acknowledge an aspect of reality or experience. Rationalization is providing logical-sounding reasons to justify unacceptable behaviors or feelings. Splitting is seeing individuals as all good or all bad, with no middle ground.

4. A client, who is on a 30-day commitment to a drug rehabilitation unit, asks the nurse if he can go for a walk on the grounds of the treatment center. When he is told that his privileges do not include walking on the grounds, the client becomes verbally abusive. Which approach will the nurse take?

• A. Call a staff member to escort the client to his room.
• B. Tell the client to talk to his healthcare provider about his privileges.
• C. Remind the client of the unit rules.
• D. Ignore the client's inappropriate behavior.

Correct answer: C

Rationale: (C) is the correct approach in this situation as it reinforces unit rules, setting clear boundaries and expectations. By reminding the client of the unit rules, the nurse is helping to maintain a safe and structured environment within the drug rehabilitation unit. (A) is unnecessary since the client's behavior does not warrant immediate physical intervention. (B) is not ideal because the client's privileges have already been explained, and suggesting he speak to his healthcare provider may not address the immediate issue. (D) is not appropriate as addressing inappropriate behavior is essential in a therapeutic setting.

5. A client with schizophrenia is experiencing distressful thoughts secondary to paranoia. Which intervention(s) should the LPN/LVN include in the plan of care? Select one intervention that does not apply.

• A. Avoid laughing when near the client
• B. Whisper when communicating near the client
• C. Increase socialization of the client among peers
• D. Have the client sign a written release of information form

Correct answer: B

Rationale: The correct intervention for a client with schizophrenia experiencing distressful thoughts secondary to paranoia is to avoid laughing when near the client. This is important as laughter can be misinterpreted and exacerbate the client's paranoia. Whispering when communicating near the client is not an appropriate intervention as it may lead the client to think secretive or negative information is being shared about them, further fueling their paranoia. Increasing socialization among peers can help provide support and reduce feelings of isolation, while having the client sign a written release of information form is not directly related to managing paranoia and distressful thoughts.

Similar Questions