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MH CH 13 part 3

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wipimebe's version from 2015-10-06 21:50

Section

35. You are working with a client who was diagnosed with schizophrenia 4 years ago when he was 20 years old. This client has been able to work at his mechanicÕs assistant job on and off, but recently this client lost his job because his symptoms have not responded well to medication. The nurse in the clinic will give this client which of the following nursing diagnoses?

 

a. Altered Role Performance
b. Altered Family Processes
c. Risk for Injury
d. Self-Esteem Disturbance

 

ANS: A
Altered Role Performance would be the most appropriate goal for this client. The client is not able to effectively perform in his role as an employee due to the symptoms related to his illness.

 

36. A client is admitted to the behavioral health unit in the hospital after the police pick the client up for running in the streets naked and saying that he is the emperor of a mystical land. The nursing diagnosis is Altered Thought Processes. A realistic and measurable short-term goal for this client would be which of the following goals?

 

a. Within 3 days, the client will be able to stay in a reality-based conversation for 30 minutes.
b. By discharge, the client will have a different perception of his appearance and role.
c. Within 1 day, the client will communicate coherently.
d. By discharge, the client will realize that even emperors are expected to wear clothes.

 

ANS: A
The admission information regarding the client running in the streets naked or voicing delusions of grandeur indicate that the client is out of touch with reality. The most appropriate outcome to address the clientÕs thought process is that the client would be able to stay in a reality-based conversation for 30 minutes. This outcome is both measurable and realistic.

 

37. A client with schizophrenia sees the nurse at the day program. The client has a lot of difficulty being with others and is socially isolated. She reports staying in her apartment alone without visitors, and she usually leaves the daily group meeting after only 5 minutes. Identify from the following a realistic short-term goal for this client for the nursing diagnosis of Impaired Social Interaction.

 

a. The client will verbalize that she has called one person on the telephone each day for 3 days.
b. The client will stay during the entire group meeting without being restless within 1 week.
c. The client will be able to socialize adequately with others within 1 month.
d. The client will organize a party for the members of the group within 6 monthsÕ time.

 

ANS: A
A realistic short-term goal for the client would be to verbalize that she has called one person on the phone each day for 3 days. The other options are more long-term outcomes, which will require more time to achieve.

 

38. Which of the following interventions would be MOST helpful for a client experiencing auditory hallucinations?

 

a. Place the client alone in a seclusion room.
b. Assign the client to play volleyball.
c. Interrupt the clientÕs voices by getting the client to talk to you.
d. Tell the client there are no voices.

 

ANS: C
The most effective intervention when a client is experiencing auditory hallucinations is to interrupt the clientÕs voices by getting the client to talk to you. Placing the client in seclusion may only enhance the hallucinations. If the client is experiencing auditory hallucinations, a competitive game of volleyball would not be appropriate. Telling the client there are no voices would challenge the client. It would be better if the nurse stated that she recognizes that the voices are real to the client.

 

39. The nurse is working with a newly admitted suspicious client with schizophrenia. Which of the following would the nurse do first?

 

a. Take a complete physical and social history.
b. Set limits, and spell out the rules before anything else.
c. Have the client prepare for a shower and body search.
d. Introduce oneself, and work on building trust.

 

ANS: D
When working with a newly admitted suspicious client with schizophrenia, the nurse should first introduce herself and begin building trust. This first encounter will establish who the nurse is and form the foundation for the nurse-client relationship. It is through this relationship that trust is developed.

 

40. Evaluation of nursing care is based on:

 

a. measurable outcomes
b. effectiveness of interventions
c. client satisfaction
d. time allowed for success

 

ANS: A
Evaluation of nursing care is based on measurable outcomes. For an outcome to be measurable, it should state a timeline for achievement and it should be realistic.

 

41. A client experiencing paranoid delusion states, ÒThey are conspiring against me; theyÕre after me all night.Ó Which of the following responses by the nurse would be the MOST empathetic?

 

a. That sounds frightening.
b. You canÕt sleep?
c. This cannot be true.
d. You are having a delusion.

 

ANS: A
The most empathetic response would be to acknowledge that the delusion sounds frightening. This response would address the clientÕs feelings. The other three options do not address feelings or demonstrate that the nurse is caring.

 

42. Negative symptoms of schizophrenia include:

 

a. hallucinations
b. disordered thought
c. flattened affect
d. delusions

 

ANS: C
One of the negative symptoms of schizophrenia is flattened affect. Other negative symptoms include poverty of speech, lack of motivation, and symptoms of depression. Hallucinations, disordered thinking, and delusions are positive symptoms of schizophrenia.

 

43. Recent research by Beebe (2002) examined the perceptions and experiences of persons with schizophrenia who were recently discharged from a hospital stay. The MOST frequent problems faced by these persons included all but which of the following?

 

a. having difficulty managing their medications
b. experiencing psychiatric symptoms
c. choosing among several job offers
d. having social problems and family conflicts

 

ANS: C
BeebeÕs 2002 research found that the most frequent problems faced by the subjects included difficulty managing medications, psychiatric symptoms, and social problems. Choosing among several job offers was not identified as one of the major problems faced.

 

44. During a one-to-one conversation with a client, the nurse begins to verbalize a delusion of persecution. The priority action is for the nurse to do which of the following?

 

a. ask the client to tell her more
b. redirect the conversation back to reality
c. engage the client and enter into the delusion
d. argue with the client over the reality of the delusion

 

ANS: B
The priority action is for the nurse to redirect the conversation back to reality. The nurse should never ask the client to tell her more, enter into the delusion, or argue with the client over the reality of the delusion.

 

45. A client with schizophrenia is in the rehabilitative phase. Which nursing diagnosis would be appropriate for the nurse to use during this phase?

 

a. Disordered Thought Process, related to persecutory delusions
b. Disturbed Sensory Perceptions, related to auditory hallucinations
c. Disturbed Sleep Pattern, related to fear of falling asleep
d. Social Isolation, related to absence of inability to engage in satisfying personal relationships

 

ANS: D
During the rehabilitative phase, nursing diagnoses would focus on social isolation, ineffective role performance, or ineffective therapeutic regimen management. Nursing diagnoses that focus on delusions, hallucinations, and paranoia would most commonly be used during the acute phase of the clientÕs illness.