1. D. The goal is to implement suicide precautions because the danger of suicide is when the depression lifts and the client has the energy to formulate a plan. The nurse would not encourage her to go home (1) where she could not be observed constantly. She could be moved into a room with other clients (2), but this is not the priority concern.
2. C. Mazuka is a made-up word or neologism. This characteristic is frequently present with the disorder and is a part of associative looseness. Answer (1) is not incorrect, but answer (3) is more specific. Flight of ideas is observed with a manic episode.
3. B. Because a person with this disorder tends to manage his or her life through manipulation of others, when it doesn’t work, the anxiety level goes up. The nurse should never allow the client to manipulate. Answers (2) and (4) are not true.
4. A. Depersonalization is the feeling or subjective experience of separating oneself or alienation; it is also the state in which the client cannot distinguish the self from others and involves disintegration of the ego-often observed in schizophrenics as a flight from reality.
5. D. Assuming responsibility for one’s behavior includes acknowledging the behavior and may include a statement of one’s current status. It does not include making excuses, focusing outside of oneself, or blaming another.
6. C. When clients make up stories or lies, it is called confabulation. This is an attempt to fill in memory gaps caused by the destruction of the neurons. This process protects their self-esteem and should not be discouraged or confronted.
7. C. While a good nursing care plan is important, the priority would be to get the client mobilized. Even without a specific diagnosis, the nurse will realize that part of what is happening with the client is a depressed mood. Providing a structured plan of activities for the client to follow will help his mood to lift and provide a focus so that he will not be centered on internal suffering.
8. B. The major goal in crisis treatment centers is to have the client return to a prior level of functioning. At this time in a crisis, it is not therapeutic to work on the dynamics underlying the symptom (2) or make long-range plans (3). Accepting their illness (4) may be a part of returning to a prior level of functioning.
9. B. Anticipating demands (rather than ignoring them) from a hypochondriacal client will break the pattern of demanding behavior. These clients are usually fearful and anxious. Spending time with the client will be reassuring and therapeutic. Assigning various staff members (2) may be useful so no one will become overwhelmed, but it is not the primary approach.
10. C. Simply offering comfort by staying with the client and being open for communication is the most therapeutic. The other responses place an additional burden on the client if she does not wish to talk.
11. B. The best response when a client has the diagnosis of schizophrenia is to validate reality by saying the nurse doesn’t hear anything and then to explore real feelings, like fear. Answer (1) is not enough to be therapeutic; answers (2) and (4) give validity to the voices if, in fact, the client is hallucinating.
12. D. Most suggestible of suicide is the sudden sense of satisfaction or relief (perhaps from finally making the decision to commit suicide) and detachment. Hostility (1), identifying with others (2), or thinking of the future (4) do not as clearly suggest suicidal thinking.
13. D. Be positive, definite, and specific about expectations. Do not give depressed clients a choice or try to convince them to get out of bed. Physically assist the client to get up and dressed to mobilize her. Do not allow her to remain in bed (4) or try to convince her by quoting the rules of the unit (1).
14. A. A goal for this disorder should be broad-based and general, like establishing a safe, supportive environment. Other answers would more directly refer to implementation of the goal strategies.
15. A. Setting limits is important to avoid rejection of the other clients with subsequent lowering of self-esteem. Confronting the client (1) will not be productive and may just increase the annoying activity. Ignoring the behavior (2) will also be nontherapeutic, and the other clients on the unit will become even more hostile. This client will not be able to follow a rigid plan.