a nurse is assessing a client who has been diagnosed with paranoid schizophrenia which of the following findings should the nurse expect
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Nursing Elites

ATI RN

ATI Mental Health Practice B

1. A healthcare professional is assessing a client diagnosed with paranoid schizophrenia. Which of the following findings should the healthcare professional expect?

Correct answer: B

Rationale: The correct answer is B: Delusions of grandeur. Clients with paranoid schizophrenia often experience delusions of grandeur or persecution, auditory hallucinations, and a flat affect. However, the most characteristic finding for paranoid schizophrenia is the presence of delusions, which are fixed false beliefs that are not based in reality. Delusions of grandeur, where individuals believe they are exceptionally powerful or important, are commonly seen in paranoid schizophrenia. Choice A, auditory hallucinations, are more commonly associated with other types of schizophrenia such as paranoid or disorganized schizophrenia. Choice C, a flat affect, is a symptom that can be seen across various types of schizophrenia. Choice D, disorganized speech, is more indicative of disorganized schizophrenia.

2. A school nurse is assessing a female high school student who is overly concerned about her appearance. The client's mother states, 'That's not something to be stressed about!' Which is the most appropriate nursing response?

Correct answer: D

Rationale: The correct answer is D. Stress can manifest as physical or psychological. A perceived threat to self-esteem can be as stressful as a physiological change. Choice A is dismissive of the teenager's concerns and does not address the issue professionally. Choice B is incorrect as stress can result from various factors, not just loss. Choice C oversimplifies the relationship between physical condition and psychological well-being, neglecting the impact of mental stressors on overall health.

3. You have been working closely with a patient for the past month. Today he tells you he is looking forward to meeting with his new psychiatrist but frowns and avoids eye contact while reporting this to you. Which of the following responses would most likely be therapeutic?

Correct answer: B

Rationale: Choice B is the most therapeutic response as it acknowledges the discrepancy between the patient's verbal statement and nonverbal cues. By addressing both the patient's expressed anticipation and the conflicting nonverbal cues of frowning and avoiding eye contact, the responder demonstrates attentiveness to the patient's emotional state and encourages further exploration of underlying feelings. This approach fosters open communication and helps the patient feel understood and supported.

4. Which of the following statements should a healthcare professional recognize as true about defense mechanisms? Select the one that doesn't apply.

Correct answer: B

Rationale: Defense mechanisms are employed by the ego in the face of threats to biological and psychological integrity to relieve mild to moderate anxiety. They act as protective devices for the ego, not the id or superego. The id represents primal instincts, while the superego is associated with moral standards. Defense mechanisms help individuals cope with stressors by redirecting focus and are often unconscious and self-deceptive.

5. In assessing a client with major depressive disorder, which of the following findings shouldn't the nurse expect?

Correct answer: D

Rationale: In major depressive disorder, common findings include anhedonia (loss of interest or pleasure), hypersomnia (excessive sleepiness), fatigue, and feelings of worthlessness. Flight of ideas, characterized by racing thoughts and rapid speech, is typically associated with bipolar disorder during manic episodes, not major depressive disorder.

Similar Questions

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Which medication is commonly prescribed for the treatment of panic disorder?
What is the most significant consequence of the excessive use of defense mechanisms?
A client with major depressive disorder is prescribed an antidepressant. Which of the following instructions should the nurse include in the teaching? Select the one that does not apply.
A distraught, single, first-time mother cries and asks a nurse, 'How can I go to work if I can't afford childcare?' What is the nurse's initial action in assisting the client with the problem-solving process?

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