Exam (elaborations)
NSG322 Exam 3 – Questions & Complete Solutions (A+)
- Course
- Institution
NSG322 Exam 3 – Questions & Complete Solutions (A+)
[Show more]
Content preview
NSG322 Exam 3 – Questions & Complete Solutions (A+)A client has had difficulty keeping a job because of arguing with co-workers
and accusing them of conspiracy. Today this client shouts, "They're all plotting
to destroy me. Isn't that true?" what is the nurse's most therapeutic response?
a. "Everyone here is trying to help you. No one wants to harm you."
b. "Feeling that people want to destroy you must be very frightening."
c. "That is not true. People here are trying to help you if you will let them."
d. "Staff members are health care professionals who are qualified to help you."
Right Ans - ANS: B
Resist focusing on content; instead, focus on the feelings the client is
expressing. This strategy prevents arguing about the reality of delusional
beliefs. Such arguments increase client anxiety and the tenacity with which
the client holds to the delusion. The other options focus on content and
provide opportunity for argument.
A newly admitted client diagnosed with schizophrenia is hypervigilant and
constantly scans the environment. The client states, "I saw two doctors talking
in the hall. They were plotting to kill me." The nurse may correctly assess this
behavior using which term?
a. echolalia.
b. paranoia
c. a delusion of infidelity.
d. an auditory hallucination. Right Ans - ANS: B
Paranoia is an irrational fear, ranging from mild (being suspicious, wary,
guarded) to profound (believing irrationally that another person intends to
kill you).; for example, when seeing two people talking, the individual assumes
they are talking about him or her. The other terms do not correspond with the
scenario.
A client diagnosed with schizophrenia says, "My co-workers are out to get me.
I also saw two
doctors plotting to kill me." How does this client perceive the environment?
a. Disorganized
b. Dangerous
c. Supportive
d. Bizarre Right Ans - ANS: B
,The client sees the world as hostile and dangerous. This assessment is
important because the nurse can be more effective by using empathy to
respond to the client. Data are not present to support any of the other options.
When a client diagnosed with schizophrenia was discharged 6 months ago,
haloperidol was
prescribed. The client now says, "I stopped taking those pills. They made me
feel like a
robot." What are common side effects the nurse should validate with the
client?
a. Sedation and muscle stiffness
b. Sweating, nausea, and diarrhea
c. Mild fever, sore throat, and skin rash
d. Headache, watery eyes, and runny nose Right Ans - ANS: A
Typical antipsychotic drugs often produce sedation and extrapyramidal side
effects such as stiffness and gait disturbance, effects the client might describe
as making him or her feel like a "robot." The side effects mentioned in the
other options are usually not associated with typical antipsychotic therapy or
would not have the effect described by the client.
Which hallucination expressed by a client necessitates the nurse to implement
safety measures?
a. "I hear angels playing harps."
b. "The voices say everyone is trying to kill me."
c. "My dead father tells me I am a good person."
d. "The voices talk only at night when I'm trying to sleep." Right Ans - ANS:
B
The correct response indicates the client is experiencing paranoia. Paranoia
often leads to fearfulness, and the client may attempt to strike out at others to
protect self. The distracters are comforting hallucinations or do not indicate
paranoia.
A client's care plan includes monitoring for auditory hallucinations. Which
assessment findings suggest the client may be hallucinating?
a. Detachment and overconfidence
b. Darting eyes, tilted head, mumbling to self
c. Euphoric mood, hyperactivity, distractibility
d. Foot tapping and repeatedly writing the same phrase Right Ans - ANS: B
,Clues to hallucinations include eyes looking around the room as though to find
the speaker, tilting the head to one side as though listening intently, and
grimacing, mumbling, or talking aloud as though responding conversationally
to someone.
A health care provider considers which antipsychotic medication to prescribe
for a client diagnosed with schizophrenia who has auditory hallucinations and
poor social function. The client is also overweight and hypertensive. Which
drug should the nurse advocate?
a. Clozapine
b. Ziprasidone
c. Olanzapine
d. Aripiprazole Right Ans - ANS: D
Aripiprazole is a third-generation atypical antipsychotic effective against both
positive and negative symptoms of schizophrenia. It causes little or no weight
gain and no increase in glucose, high- or low-density lipoprotein cholesterol,
or triglycerides, making it a reasonable choice for a client with obesity or
heart disease. Clozapine may produce agranulocytosis, making it a poor choice
as a first-line agent. Ziprasidone may prolong the QT interval, making it a poor
choice for a client with cardiac disease. Olanzapine fosters weight gain.
A client diagnosed with schizophrenia tells the nurse, "I eat skiller. Tend to
end. Easter. It
blows away. Get it?" What is the nurse's most therapeutic response?
a. "Nothing you are saying is clear."
b. "Your thoughts are very disconnected."
c. "Try to organize your thoughts and then tell me again."
d. "I am having difficulty understanding what you are saying." Right Ans -
ANS: D
When a client's speech is loosely associated, confused, and disorganized,
pretending to
understand is useless. The nurse should tell the client that he or she is having
difficulty understanding what the client is saying. If a theme is discernible, ask
the client to talk about the theme. The incorrect options tend to place blame
for the poor communication with the client. The correct response places the
difficulty with the nurse rather than being accusatory.
A client diagnosed with schizophrenia exhibits little spontaneous movement
and demonstrates
, catatonia. Which client needs are of priority importance? a. Self-esteem
b. Psychosocial
c. Physiological
d. Self-actualization Right Ans - ANS: C
Physiological needs must be met to preserve life. A client with catatonia must
be fed by hand or tube, toileted, given range-of-motion exercises, and so forth
to preserve physiological integrity. Cattonia may also precipitate a risk for
falls; therefore, safety is a concern. Higher level needs are of lesser concern.
A client diagnosed with schizophrenia demonstrates little spontaneous
movement and has catatonia. The client's activities of daily living are severely
compromised. What will be an appropriate outcome for this client?
a. demonstrates increased interest in the environment by the end of week 1.
b. performs self-care activities with coaching by the end of day 3.
c. gradually takes the initiative for self-care by the end of week 2.
d. accepts tube feeding without objection by day 2. Right Ans - ANS: B
Outcomes related to self-care deficit nursing diagnoses should deal with
increasing ability to perform self-care tasks independently, such as feeding,
bathing, dressing, and toileting. Performing the tasks with coaching by nursing
staff denotes improvement over the complete inability to perform the tasks.
The incorrect options are not directly related to self-care activities, difficult to
measure, and unrelated to maintenance of nutrition.
A nurse observes a catatonic client standing immobile, facing the wall with
one arm extended in a salute. The client remains immobile in this position for
15 minutes, moving only when the nurse gently lowers the arm. What is the
name of this phenomenon?
a. Echolalia
b. Catatonia
c. Depersonalization
d. Thought withdrawal Right Ans - ANS: B
Catatonia is the ability to hold distorted postures for extended periods of time,
as though the client were molded in wax. Echolalia is a speech pattern.
Depersonalization refers to a feeling state. Thought withdrawal refers to an
alteration in thinking.
A nurse leads a psychoeducational group about first-generation antipsychotic
medications with six adult men diagnosed with schizophrenia. The nurse will
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller StudyHall. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $24.99. You're not tied to anything after your purchase.
Can Stuvia be trusted?
4.6 stars on Google & Trustpilot (+1000 reviews)
67479 documents were sold in the last 30 days
Founded in 2010, the go-to place to buy study notes for 15 years now