A client who has been admitted to the behavioral health unit with delusions of grandeur tells the nurse, "I am the president of the United States. Everyone needs to listen to me." What is an appropriate nursing response?
Correct Answer Rationale: This response acknowledges the client's feelings and addresses their need for validation without directly reinforcing or challenging their delusion. By shifting the conversation away from the delusion and focusing on the client's emotional state, the nurse avoids confrontation and provides a therapeutic way to engage with the client.
Question 2
The nurse enters the room of a client who has been experiencing delusions and hallucinations. As the nurse starts to speak with the client, the client says, "Did they tell you that I am an important person? I am the king of the world." What response by the nurse is appropriate?
Correct Answer Rationale: This approach validates the client's feelings and redirects the conversation away from the delusion, focusing instead on the emotional aspects of the delusion. It is therapeutic because it engages the client in a way that doesn't directly confront the delusion, offering support without reinforcing it.
Question 3
The nurse is caring for a client with schizophrenia who is experiencing delusions. The client states, "The government is monitoring my every move. They want to take me away." What is the nurse's most appropriate response?
Correct Answer Rationale: This response shows empathy and acknowledges the client's feelings while also encouraging the client to talk more about their experience. Avoiding direct confrontation or challenging the delusion allows for a therapeutic, non-judgmental conversation.
Question 4
Based on the nurse's note, what is important to include in the client's plan of care?
Chart: Chris Platts, 32, Allergies: Peanuts. 0740: Client resting in bed, no distress, VS stable. 0930: UAP reports client saying "weird" things regarding the president. 0950: Client states, "Please make sure I have access to a telephone so that I don't miss my daily call from the president. I am going to be first lady one day after I marry the president." Nurse expresses to client, "I understand you feel that you have an intimate relationship with the president, but I see that he appears to be happily married to his wife."
Correct Answer Rationale: The most appropriate plan of care is ongoing reinforcement of reality when delusion is expressed. The client is exhibiting a grandiose delusion. It is essential for the nurse to gently reinforce reality without directly confronting the client's delusion or telling them it is "silly."
Question 5
Based on the nurse's note, what is important to include in the client's plan of care?
Chart: Sarah Caldwell, 45. 0740: Client restless but alert, VS: 118/74. 0800: Client reported hearing voices telling her to "get out of here before they take you." 0830: Client anxious and agitated, stating, "The healthcare providers are trying to poison me. I need to leave before it's too late." Nurse speaks calmly, providing reassurance about safety.
Correct Answer Rationale: The client is experiencing auditory hallucinations and delusions of being poisoned, which may cause anxiety and distress. Creating a calming, safe environment helps manage these symptoms by reducing external stimuli and promoting relaxation.
Question 6
Based on the nurse's note, what is important to include in the client's plan of care?
Chart: John Davis, 28. 0730: Client calm but withdrawn, VS: 130/85. 0915: Client becomes agitated and shouts, "They're watching me! They're going to kill me!" Client states, "I see them right outside my window." Nurse reassures the client, offering a calm presence.
Correct Answer Rationale: The client is experiencing persecutory delusions, believing that others are watching and intending to harm them. It is important to provide calm reassurance about their safety while avoiding directly confronting the delusion. Redirecting the client or offering an activity may also help, but safety and reassurance should be prioritized first.
Question 7
The client with a persecutory delusion says to the nurse, "The healthcare provider put something in those pills to kill me, so I am not taking them." What is an appropriate nursing response?
Correct Answer Rationale: This response acknowledges the client's belief without directly challenging or reinforcing the delusion. It also provides a reality-based response by reassuring the client that their medication came from a legitimate source.
Question 8
A client with a persecutory delusion states to the nurse, "The people in the next room are plotting against me. They're going to hurt me if I stay here." What is the most appropriate nursing response?
Correct Answer Rationale: This response acknowledges the client's feelings while reassuring them about their safety. It does not directly challenge the delusion, which could escalate the client's anxiety, but provides a comforting and supportive approach.
Question 9
A client with a delusional disorder says, "I have been chosen to save the world, and everyone needs to listen to me." What is the most appropriate response by the nurse?
Correct Answer Rationale: When responding to a client experiencing delusions, the nurse should use therapeutic communication that encourages exploration of feelings without directly challenging or reinforcing the delusion. Asking to talk about what is causing the client to feel this way acknowledges the client's emotions and opens a supportive dialogue.
Question 10
The assessment of a client demonstrates the presence of several psychiatric symptoms. Which symptom should be the most concerning to the nurse?
Correct Answer Rationale: Command auditory hallucinations are the most concerning symptom in this scenario. These hallucinations involve hearing voices that instruct the person to perform certain actions, and they can pose a significant risk to the client's safety.
Question 11
The nurse is assessing a client who is experiencing psychiatric symptoms. Which psychotic symptom should the nurse be most concerned about?
Correct Answer Rationale: Delusions of persecution are the most concerning symptom. These delusions can lead to extreme anxiety, agitation, and even violent behavior if the client feels threatened and may be at risk of harm to themselves or others.
Question 12
A client with schizophrenia is demonstrating several symptoms. Which symptom is most likely to indicate that the client is at risk for harm to themselves or others?
Correct Answer Rationale: Auditory hallucinations that command the client to harm others are the most concerning, as they directly threaten the safety of both the client and others. Command hallucinations instructing harmful actions require immediate intervention to prevent potential harm.
Question 13
The nurse is caring for a client on an acute mental health unit. The client reports hearing voices that are stating, "kill your healthcare provider." Which action should the nurse take first?
Correct Answer Rationale: The first action the nurse should take is to initiate one-to-one observation of the client. This is the most immediate and important response because the client is experiencing command auditory hallucinations instructing harmful behavior.
Question 14
The nurse is caring for a client with schizophrenia who is experiencing auditory hallucinations. The client reports hearing voices telling them to "hurt others." What should the nurse do first?
Correct Answer Rationale: The first priority is to ensure the safety of the client and others on the unit. Since the client is hearing voices instructing them to hurt others, there is a risk for harm. Immediate action to protect the client and others is essential.
Question 15
The nurse is caring for a client diagnosed with schizophrenia who is experiencing auditory hallucinations. The client reports hearing voices telling them to harm themselves. What is the nurse's priority intervention?
Correct Answer Rationale: The priority intervention is to ensure the client is in a safe environment and initiate close observation. Since the client is hearing voices instructing them to harm themselves, immediate safety is the most critical concern.