Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
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? .
A. "The aliens are going to abduct me tonight.”.
A rationale: This statement indicates a delusion, not a command hallucination. Delusions are fixed false beliefs that are not based in reality.
B. "The voices told me to quit eating the food here.”. .
B rationale: This statement indicates a command hallucination. Command hallucinations involve hearing voices that direct the person to take action.
C. "Are you planning to kill me?" .
C rationale: This statement indicates paranoia, not a command hallucination. Paranoia involves intense anxious or fearful feelings and thoughts often related to persecution or threat.
D. "Can you see these spiders crawling all over me?" .
D rationale: This statement indicates a visual hallucination, not a command hallucination. Visual hallucinations involve seeing things that aren’t there.
This question is an excerpt from Nurse Dive's nursing test bank - ATI PN Mental health DEC 2023 Proctored Exam. Take the full exam now
Full Explanation
Choice A rationale:
This statement indicates a delusion, not a command hallucination. Delusions are fixed false beliefs that are not based in reality.
Choice B rationale:
This statement indicates a command hallucination. Command hallucinations involve hearing voices that direct the person to take action.
Choice C rationale:
This statement indicates paranoia, not a command hallucination. Paranoia involves intense anxious or fearful feelings and thoughts often related to persecution or threat.
Choice D rationale:
This statement indicates a visual hallucination, not a command hallucination. Visual hallucinations involve seeing things that aren’t there.
Similar Questions
A nurse is reinforcing teaching with a client who has bipolar disorder and has a new prescription for lithium.
To address possible adverse effects, the nurse should include that which of the following laboratory values will be monitored while the client is taking this medication? .
A. Liver enzymes
A rationale: While liver enzymes are important to monitor for many medications, they are not typically affected by lithium.
B. Uric acid.
B rationale: Uric acid levels are not typically affected by lithium.
C. Sodium level.
C rationale: Lithium can affect the sodium levels in the body, making it important to monitor these levels while taking this medication.
D. Erythrocyte sedimentation rate.
D rationale: Erythrocyte sedimentation rate is not typically affected by lithium.
Full Explanation
Choice A rationale:
While liver enzymes are important to monitor for many medications, they are not typically affected by lithium.
Choice B rationale:
Uric acid levels are not typically affected by lithium.
Choice C rationale:
Lithium can affect the sodium levels in the body, making it important to monitor these levels while taking this medication.
Choice D rationale:
Erythrocyte sedimentation rate is not typically affected by lithium.
A nurse is caring for a client who has depression and reports only sleeping a few hours each night.
Which of the following instructions should the nurse give the client to promote sleep? .
A. "You should drink a glass of wine 1 hour before you go to bed.”.
A rationale: Alcohol can interfere with sleep patterns and should not be used as a sleep aid.
B. "You should take a nap after lunch.”. .
B rationale: Napping can make it harder to fall asleep at night.
C. "You should eat a meal just prior to bedtime.”. .
C rationale: Eating just before bedtime can cause discomfort and disrupt sleep.
D. "You should limit yourself to two caffeinated beverages per day.”. .
D rationale: Limiting caffeine intake can help improve sleep, as caffeine is a stimulant that can interfere with the ability to fall asleep.
Full Explanation
Choice A rationale:
Alcohol can interfere with sleep patterns and should not be used as a sleep aid.
Choice B rationale:
Napping can make it harder to fall asleep at night.
Choice C rationale:
Eating just before bedtime can cause discomfort and disrupt sleep.
Choice D rationale:
Limiting caffeine intake can help improve sleep, as caffeine is a stimulant that can interfere with the ability to fall asleep.
A nurse in a mental health facility is caring for a client who has antisocial personality disorder and alcohol dependency.
The nurse should encourage the client to participate in which of the following groups? .
A. Psychodrama
A rationale: Psychodrama is a therapeutic approach that uses dramatic role play to help clients gain insight into their feelings and behaviors. However, it may not be the most effective for a client with antisocial personality disorder and alcohol dependency.
B. Crisis intervention.
B rationale: Crisis intervention is a short-term therapy to stabilize a client during an acute crisis. It may not address the long-term needs of a client with antisocial personality disorder and alcohol dependency.
C. Dual diagnosis treatment.
C rationale: Dual diagnosis treatment is designed for clients who have a mental health disorder and a substance use disorder. This would be the most appropriate for a client with antisocial personality disorder and alcohol dependency.
D. Codependency support.
D rationale: Codependency support groups are typically for family members and friends of individuals with substance use disorders. They may not be the most beneficial for the client themselves.
Full Explanation
Choice A rationale:
Psychodrama is a therapeutic approach that uses dramatic role play to help clients gain insight into their feelings and behaviors. However, it may not be the most effective for a client with antisocial personality disorder and alcohol dependency.
Choice B rationale:
Crisis intervention is a short-term therapy to stabilize a client during an acute crisis. It may not address the long-term needs of a client with antisocial personality disorder and alcohol dependency.
Choice C rationale:
Dual diagnosis treatment is designed for clients who have a mental health disorder and a substance use disorder. This would be the most appropriate for a client with antisocial personality disorder and alcohol dependency.
Choice D rationale:
Codependency support groups are typically for family members and friends of individuals with substance use disorders. They may not be the most beneficial for the client themselves.