1. A nurse is caring for a client who has schizophrenia and is experiencing

auditory hallucinations. The nurse hears the client talking to himself in his

room. Which of the following actions should the nurse take?

a) Ignore the client's behavior and document it in the chart.

b) Enter the room and ask the client what he is talking about.

c) Enter the room and distract the client with a different topic.

d) Enter the room and acknowledge the client's feelings without

reinforcing the hallucinations.*

Rationale: The nurse should enter the room and acknowledge the client's

feelings without reinforcing the hallucinations. This shows empathy and

respect for the client's reality, while also helping him to focus on realitybased stimuli. Ignoring the client's behavior or asking him what he is

talking about might increase his anxiety or agitation. Distracting the client

with a different topic might be ineffective or disrespectful.

2. A nurse is conducting a mental status examination for a client who has

major depressive disorder. Which of the following findings should the

nurse expect?

a) Increased psychomotor activity and pressured speech.

b) Decreased attention span and impaired memory.*

c) Elevated mood and grandiose delusions.

d) Paranoid thoughts and perceptual disturbances.

Rationale: The nurse should expect to find decreased attention span and

impaired memory in a client who has major depressive disorder. These are

signs of cognitive impairment that often accompany depression. Increased

psychomotor activity and pressured speech are more indicative of mania

or hypomania. Elevated mood and grandiose delusions are also signs of

mania or psychotic disorders. Paranoid thoughts and perceptual

disturbances are signs of schizophrenia or other psychotic disorders.

3. A nurse is planning care for a client who has bipolar disorder and is

experiencing a manic episode. Which of the following interventions

should the nurse include in the plan?

a) Provide frequent snacks and fluids to prevent dehydration and weight

loss.*

b) Encourage the client to participate in group activities to enhance