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A nurse is collecting data from a client who has schizophrenia. Which of the following client statements indicates that the client is experiencing a command hallucination? Can you see these spiders crawling all over me?' "Are you planning to kill me?" The aliens are going to abduct me tonight."...

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  • 12 september 2024
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PatrickKaylian
Mental health CMS
A nurse is collecting data from a client who has schizophrenia. Which of the following client statements
indicates that the client is experiencing a command hallucination?




Can you see these spiders crawling all over me?'



"Are you planning to kill me?"



The aliens are going to abduct me tonight."



"The voices told me to quit eating the food here." - ✔️✔️"The voices told me to quit eating the food
here."



A nurse is speaking with the sibling of a client who refuses to see visitors. Which of the following actions
should the nurse take?



Arrange for the sibling to visit the client in the dayroom.



Refer the sibling to the client's provider.



Encourage the client to visit with the sibling.



Tell the sibling the client does not want visitors. - ✔️✔️Tell the sibling the client does not want visitors.



A nurse is reviewing the laboratory results of a client who has anorexia nervosa. Which of the following
results should the nurse report to the

provider?

,Potassium 2.8 mEg/L



WBC count 6,000/mm



O HDA1C 4%



Sodium 138 mEg/L - ✔️✔️Potassium 2.8 mEg/L



A nurse is contributing to the plan of care for a client who has bipolar disorder and whose admission was
voluntary. For which of the following

interventions should the nurse confirm that the client has given informed consent?



Recelving light therapy



Participating in a group exercise program



Attending a cognitive behavioral therapy class



Taking an experimental medication - ✔️✔️Taking an experimental medication




A nurse is caring for a male client who is to begin therapy with valproic acid. Which of the following
diagnostic results should the nurse plan to review before administering the first dose?



Prostate specific antigen test



Liver function tests



Chest x-ray

, Urine culture - ✔️✔️Liver function tests



A nurse is caring for a newly admitted client who has schizophrenia and hearing loss. Which of the
following actions should the nurse take first when communicating with the client?



Face the client when speaking so the client can read lips.



Evaluate the client's understanding of the message.



Contact a sign-language Interpreter to communicate with the client.



Determine how the client prefers to communicate. - ✔️✔️Face the client when speaking so the client
can read lips



A nurse is collecting data from an adult client in an outpatient mental health clinic. The nurse should
identify which of the following events as a potential cause of a maturational crisis?



A child leaving for college



Divorce



Loss of job



Motor-vehicle crash - ✔️✔️Loss of job



A nurse is collecting data from an older adult client who was admitted with heart failure. The nurse
should report which of the following findings to the provider as an indication of delirium?



Demonstrates obsessive behaviors

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