Exam 4

A nurse is caring for a client who has schizophrenia. The client spends a great deal of time repeating rhyming syllables such as, "Me, see, bee, tree." The nurse recognizes that the client is demonstrating which of the following positive manifestations of schizophrenia?

• Clang association

• Echolalia

• Magical thinking

• Word salad

A nurse in an outpatient mental health clinic is interviewing a client who has schizophrenia and appears to be experiencing auditory hallucinations. Which of the following actions should the nurse take first?

• Teach the client strategies to decrease the hallucinations.

• Identify whether the client is on antipsychotic medications.

• Distract the client from the hallucination

• Explore what the voices are saying to the client.

A nurse is assessing a client who has been taking an antipsychotic medication for 6 years. The provider has started tapering the clients dosage. The nurse should monitor for which of the following manifestations of tardive dyskinesia?

• Muscular weakness

• Muscle spasms

• Involuntary tongue protrusion

• Uncontrolled rolling of the eyes

A nurse is admitting a client who has schizophrenia. During the initial interview, which of the following behaviors should the nurse identify as a positive manifestation of schizophrenia?

• Anhedonia

• Avolition

• Flat affect

• Hallucinations

A nurse is caring for a client who has alcohol use disorder. Following the alcohol withdrawal, which of the following medications should the nurse expect to administer during maintenance?

• Methadone

• Disulfiram

• Chlordiazepoxide

• Naloxone

A nurse is planning care for a client with borderline personality disorder who self-mutilates. Which of the following treatment approaches should the nurse plan to take?

• Restrict participation in group therapy sessions.

• Establish consequences for self-mutilation

• Maintain close observation of the client.

• Provide an unstructured environment

The nurse is caring for a client who has borderline personality disorder. The client has previously identified another nurse as his favorite, stating, "He's the best nurse ever." When that nurse calls in sick, which of the following statements indicates the client is using a splitting as a method of coping?

• "He's the worst nurse that has ever taken care of me."

• "You're just lying to me. He's not really sick."

• "He's my favorite nurse. I'm really worried about him."

• "If anyone else tries to take care of me, I'm going to get really upset."

A nurse is preparing to administer fluphenazine deconoate 12.5 mg subcutaneously. Fluphenazine decanoate 25 mg/mL is available. How many mL should the nurse administer per dose? (Fill in the blank with numerical value only, round the answer to the nearest tenth, and use a leading zero if applicable. Do not use a trailing zero)

A nurse is caring for a client who is showing evidence of addiction to a pain medication prescribed for rheumatoid arthritis. When questioned about the use of the medication, the client states, "It is not an illegal drug." Which of the following defense mechanisms is the client using?

• Displacement

• Rationalization

• Projection

• Sublimation

A nurse in an emergency room is assessing a client who has cocaine intoxication. Which of the following findings should the nurse expect?

• Low blood pressure

• Dilated pupils

• Conjunctival redness

• Decreased body temperature