Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is discussing schizophrenia spectrum disorders with a client.
The client states, "My friend says that before I started hearing voices, I stopped hanging out with them.
Why is that?" Which of the following responses should the nurse make?
A. "That is very interesting.We are not sure why people start to isolate themselves.”.
While it’s interesting to consider why people isolate themselves, this statement does not provide a clear explanation for the behavior.
B. "Do you think of yourself as more of an introvert? That makes a difference with how you socialize.”.
Being an introvert or extrovert doesn’t necessarily correlate with the onset of schizophrenia symptoms.
C. "Before symptoms of schizophrenia begin, people often isolate themselves.This is an early warning.”.
Before symptoms of schizophrenia begin, people often isolate themselves. This is known as the prodromal phase of schizophrenia.
D. "Were you avoiding your friend so that you could hear the voices more clearly?". .
Avoiding friends to hear voices more clearly is not a typical behavior associated with the onset of schizophrenia.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Rn Custom Nurs 120 Psychiatric Nursing Fa23 Proctored Exam 2. Take the full exam now
Full Explanation
Choice A rationale:
While it’s interesting to consider why people isolate themselves, this statement does not provide a clear explanation for the behavior.
Choice B rationale:
Being an introvert or extrovert doesn’t necessarily correlate with the onset of schizophrenia symptoms.
Choice C rationale:
Before symptoms of schizophrenia begin, people often isolate themselves. This is known as the prodromal phase of schizophrenia.
Choice D rationale:
Avoiding friends to hear voices more clearly is not a typical behavior associated with the onset of schizophrenia.
Similar Questions
A nurse is caring for a client who was recently diagnosed with somatic symptom disorder.
The client says to the nurse, "I don't understand, they can't find anything medically wrong with me. I guess I will never feel better.”. Which of the following responses is the most therapeutic?
A. "Why do you feel like you will never get better? Do you not have confidence in the medical team?".
Asking why the client feels they will never get better might come across as dismissive or confrontational.
B. "We will work with you to help you develop ways to manage your symptoms that are caused by the disorder.”.
This response acknowledges the client’s feelings and offers a supportive approach to managing the symptoms of somatic symptom disorder. This disorder is characterized by a significant focus on physical symptoms that cause major distress and/or problems functioning. The main treatment is psychotherapy, and medication might be given in some cases.
C. "Let's focus on the physical symptoms that you have.”.
Focusing only on the physical symptoms might not address the emotional distress that the client is experiencing.
D. "Although there isn't a cure for this disorder, I am sure you will feel better someday.”.
While it’s important to offer hope, this response might come across as dismissive of the client’s current feelings.
Full Explanation
Choice A rationale:
Asking why the client feels they will never get better might come across as dismissive or confrontational.
Choice B rationale:
This response acknowledges the client’s feelings and offers a supportive approach to managing the symptoms of somatic symptom disorder. This disorder is characterized by a significant focus on physical symptoms that cause major distress and/or problems functioning. The main treatment is psychotherapy, and medication might be given in some cases.
Choice C rationale:
Focusing only on the physical symptoms might not address the emotional distress that the client is experiencing.
Choice D rationale:
While it’s important to offer hope, this response might come across as dismissive of the client’s current feelings.
A nurse in an acute mental health unit is admitting a client who has bipolar disorder.
Which of the following findings supports the admitting diagnosis of acute mania?
A. The client's spouse reports that the client has recently gained weight.
Weight gain is not typically associated with acute mania in bipolar disorder.
B. The client responds to questions with disorganized speech.
Disorganized speech can be a symptom of acute mania, which is characterized by increased energy, feelings of euphoria, racing thoughts, risky behaviors, and an inflated self-image.
C. The client reports that voices are telling him to write a novel.
While hallucinations can occur in severe bipolar episodes, the client reporting that voices are telling him to write a novel is not specifically indicative of acute mania.
D. The client is dressed in all black.
Dressing in all black is not a specific symptom of acute mania.
Full Explanation
Choice A rationale:
Weight gain is not typically associated with acute mania in bipolar disorder.
Choice B rationale:
Disorganized speech can be a symptom of acute mania, which is characterized by increased energy, feelings of euphoria, racing thoughts, risky behaviors, and an inflated self-image.
Choice C rationale:
While hallucinations can occur in severe bipolar episodes, the client reporting that voices are telling him to write a novel is not specifically indicative of acute mania.
Choice D rationale:
Dressing in all black is not a specific symptom of acute mania.
A nurse is reviewing the medical record of a client who performs self-injury.
Which of the following information should the nurse identify as placing the client at risk for self-harm behaviors?
A. The client has a history of bulimia nervosa.
While bulimia nervosa can be associated with self-harm behaviors, it is not as strongly linked as borderline personality disorder.
B. The client has a parent who has dependent personality disorder.
Having a parent with dependent personality disorder is not a specific risk factor for self-harm behaviors.
C. The client has borderline personality disorder.
Borderline personality disorder is strongly associated with self-harm behaviors.
D. The client recently received a promotion at work.
Receiving a promotion at work is generally considered a positive event and is not typically associated with an increased risk of self-harm behaviors.
Full Explanation
Choice A rationale:
While bulimia nervosa can be associated with self-harm behaviors, it is not as strongly linked as borderline personality disorder.
Choice B rationale:
Having a parent with dependent personality disorder is not a specific risk factor for self-harm behaviors.
Choice C rationale:
Borderline personality disorder is strongly associated with self-harm behaviors.
Choice D rationale:
Receiving a promotion at work is generally considered a positive event and is not typically associated with an increased risk of self-harm behaviors.