Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
The nurse is caring for a newly admitted client diagnosed with catatonic schizophrenia. Which of the following behaviors should the nurse document to be consistent with catatonic schizophrenia? The client:
A. Laughs when watching a sad movie.
Laughing inappropriately, such as when watching a sad movie, can be a symptom of schizophrenia, but it is not specific to the catatonic subtype. Inappropriate affect may occur in schizophrenia but does not solely characterize catatonic behavior.
B. Maintains an immobilized state for several hours.
Catatonic schizophrenia is marked by periods of immobility or stupor. A client who maintains an immobilized state for several hours is displaying a classic sign of catatonia. During these periods, the client may be mute, rigid, and resistant to movement, which are key features of this condition.
C. Refuses to eat any unwrapped foods.
Refusing to eat certain types of food is not specifically indicative of catatonic schizophrenia. While individuals with schizophrenia may have unusual preferences or fears related to food, this behavior could be related to a variety of factors and is not a definitive sign of catatonia.
D. Uses a rhyming form of speech.
Using a rhyming form of speech, known as clang associations, can be seen in schizophrenia but is more characteristic of disorganized thinking associated with the disorder rather than catatonia. Catatonia involves motoric symptoms rather than speech patterns.
This question is an excerpt from Nurse Dive's nursing test bank - Ati N133 Mental Health Proctored Exam 1. Take the full exam now
Full Explanation
Choice A Reason:
Laughing inappropriately, such as when watching a sad movie, can be a symptom of schizophrenia, but it is not specific to the catatonic subtype. Inappropriate affect may occur in schizophrenia but does not solely characterize catatonic behavior.
Choice B Reason:
Catatonic schizophrenia is marked by periods of immobility or stupor. A client who maintains an immobilized state for several hours is displaying a classic sign of catatonia. During these periods, the client may be mute, rigid, and resistant to movement, which are key features of this condition.
Choice C Reason:
Refusing to eat certain types of food is not specifically indicative of catatonic schizophrenia. While individuals with schizophrenia may have unusual preferences or fears related to food, this behavior could be related to a variety of factors and is not a definitive sign of catatonia.
Choice D Reason:
Using a rhyming form of speech, known as clang associations, can be seen in schizophrenia but is more characteristic of disorganized thinking associated with the disorder rather than catatonia. Catatonia involves motoric symptoms rather than speech patterns.
Similar Questions
A nurse in a psychiatric unit is caring for several clients. Which of the following clients should the nurse recommend for group therapy?
A. A client exhibiting psychotic behavior.
A client exhibiting psychotic behavior may not be the best candidate for group therapy initially, as they might be experiencing delusions, hallucinations, or disorganized thinking that could disrupt the group process and might not be able to participate effectively. Individual therapy might be more appropriate until the client's symptoms are better managed.
B. A client admitted 5 hours ago for acute mania.
A client who was admitted 5 hours ago for acute mania is likely still experiencing heightened levels of energy, impulsivity, and possibly erratic behavior. They may not be able to engage in group therapy effectively and could benefit from stabilization before participating in a group setting.
C. A client who has been taking lithium for 2 weeks for depression.
A client who has been taking lithium for 2 weeks for depression is likely to have achieved some level of stabilization of their mood. Lithium is a mood stabilizer used to treat bipolar disorder and depression, and after 2 weeks, the client may be ready to engage with others in a therapeutic group setting.
D. A client who is in a manic state.
A client who is in a manic state, similar to the client in choice B, may not be suitable for group therapy due to potential disruptive behavior and difficulty focusing on the group process. It's important for the client to receive individual attention to manage the mania before joining group therapy. Question 43
Full Explanation
Choice A Reason:
A client exhibiting psychotic behavior may not be the best candidate for group therapy initially, as they might be experiencing delusions, hallucinations, or disorganized thinking that could disrupt the group process and might not be able to participate effectively. Individual therapy might be more appropriate until the client's symptoms are better managed.
Choice B Reason:
A client who was admitted 5 hours ago for acute mania is likely still experiencing heightened levels of energy, impulsivity, and possibly erratic behavior. They may not be able to engage in group therapy effectively and could benefit from stabilization before participating in a group setting.
Choice C Reason:
A client who has been taking lithium for 2 weeks for depression is likely to have achieved some level of stabilization of their mood. Lithium is a mood stabilizer used to treat bipolar disorder and depression, and after 2 weeks, the client may be ready to engage with others in a therapeutic group setting.
Choice D Reason:
A client who is in a manic state, similar to the client in choice B, may not be suitable for group therapy due to potential disruptive behavior and difficulty focusing on the group process. It's important for the client to receive individual attention to manage the mania before joining group therapy.
Question 43
A nursing instructor teaches students about the purpose of using the nursing process in the care of psychiatric clients. Which of the following statements by a student indicates that learning has occurred?
A. "The nursing process is a method for interviewing."
While interviewing is a component of the nursing process, specifically during the assessment phase, describing the nursing process solely as a method for interviewing is incomplete. The nursing process encompasses much more, including diagnosis, planning, implementation, and evaluation.
B. "The nursing process is used to assist clients to adapt to stressors."
This statement accurately reflects the purpose of the nursing process. It is a systematic method used by nurses to assist clients in adapting to stressors, whether they are physical, psychological, or social. The process involves assessing the client's needs, diagnosing issues, planning and implementing interventions, and evaluating the outcomes.
C. "The nursing process is used primarily to minimize allegations of negligence."
The nursing process does play a role in minimizing allegations of negligence by providing a structured approach to care, but this is not its primary purpose. The main goal is to deliver individualized and effective care to clients, not just to protect against legal issues.
D. "The nursing process is used to provide support for the psychiatric diagnosis."
Supporting a psychiatric diagnosis is part of the nursing process, but the statement is too narrow to describe the overall purpose. The nursing process is used to plan and provide personalized care, which goes beyond just supporting a diagnosis.
Full Explanation
Choice A Reason:
While interviewing is a component of the nursing process, specifically during the assessment phase, describing the nursing process solely as a method for interviewing is incomplete. The nursing process encompasses much more, including diagnosis, planning, implementation, and evaluation.
Choice B Reason:
This statement accurately reflects the purpose of the nursing process. It is a systematic method used by nurses to assist clients in adapting to stressors, whether they are physical, psychological, or social. The process involves assessing the client's needs, diagnosing issues, planning and implementing interventions, and evaluating the outcomes.
Choice C Reason:
The nursing process does play a role in minimizing allegations of negligence by providing a structured approach to care, but this is not its primary purpose. The main goal is to deliver individualized and effective care to clients, not just to protect against legal issues.
Choice D Reason:
Supporting a psychiatric diagnosis is part of the nursing process, but the statement is too narrow to describe the overall purpose. The nursing process is used to plan and provide personalized care, which goes beyond just supporting a diagnosis.
The nurse is caring for a client in an acute mental health unit. The client states, “I believe my food is poisoned.” Which of the following should be an appropriate action by the nurse?
A. Taking steps to prevent the client from verbalizing the delusional thoughts.
Taking steps to prevent the client from verbalizing delusional thoughts is not therapeutic. It can lead to the client feeling misunderstood and unsupported. Nurses should provide a safe environment where clients feel comfortable expressing their thoughts and feelings.
B. Allowing the client to select food from vending machines.
Allowing the client to select food from vending machines can be a temporary measure to address the immediate concern of the client’s fear of being poisoned. It provides a sense of control over their situation and may help to reduce anxiety related to eating.
C. Explaining that others eat the same food and feel safe.
Simply explaining that others eat the same food and feel safe may not be effective for a client experiencing delusions. Delusions are fixed beliefs that are not easily changed by logical explanations or evidence to the contrary.
D. Encouraging the client to discuss why someone would poison the food.
Encouraging the client to discuss why someone would poison the food might validate the delusion and could reinforce the false belief. It’s important to acknowledge the client’s feelings without supporting the delusional content.
Full Explanation
Choice A Reason:
Taking steps to prevent the client from verbalizing delusional thoughts is not therapeutic. It can lead to the client feeling misunderstood and unsupported. Nurses should provide a safe environment where clients feel comfortable expressing their thoughts and feelings.
Choice B Reason:
Allowing the client to select food from vending machines can be a temporary measure to address the immediate concern of the client’s fear of being poisoned. It provides a sense of control over their situation and may help to reduce anxiety related to eating.
Choice C Reason:
Simply explaining that others eat the same food and feel safe may not be effective for a client experiencing delusions. Delusions are fixed beliefs that are not easily changed by logical explanations or evidence to the contrary.
Choice D Reason:
Encouraging the client to discuss why someone would poison the food might validate the delusion and could reinforce the false belief. It’s important to acknowledge the client’s feelings without supporting the delusional content.