NCLEX

Care of Psychiatric
SRI RENGGANI
 Question
A client with dysthymia has a nursing diagnosis of self-
esteem disturbance related to feelings of worthlessness.
Which goal reflects an increase in the clients self-esteem?
a. The client identifies two personal behaviors that alienate
others.
b. The client attends and participates in morning goal-
setting activities.
c. The client eats in the cafetaria with other clients from the
unit.
d. The client identifies one or two positive self-attributes.

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 Incorrect

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 Incorrect

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 Incorrect

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 Answer
Answer D is correct. An increase in the clients self-
esteem is evidenced by the fact that he/she can recognize
positive self attributes.
Answer a, b, and c are incorrect because they do not reflect
an increase in self-esteem

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 Thank
youuuuuu

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Name : Bambang P.S
Nim : 34403115013
QUESTION

A client walks in to the mental health outpatient center and states, I ve had it. I cant go
on any longer. Youve got to help me. The nurse asks the client to be seated in a
private interview room. Which action should the nurse take next?
a. Reassure the client that someone will help him soon
b. Assess the cllients insurace coverage.
c. Find out more about what is happening to the client.
d. Call the clients family to come and provide support
answer
Answer is : C
Rational : The nurse must assess the client and his situation
before the appropriate action can be determined.
THANK YOU
Anne N
During a home visit, the nurse discovers that
the client is less verbal, less active, less
responsive to directions, severly anxious, and
more stuporous. The nurse interprets these
findings as indicating that the client is having
an exacerbation of which of the following
types of schizophrenia?

1. Disorganized
2. Paranoid
3. Undifferentiated
4. Catatonic
Answer
(4) the client is exhibiting symptoms of becoming
immobilized that are classic pecursors to
catatonic behaviors. Disorganized schizophrenia
is characterized by disorganized speech and
behaviors. Paranoid schizophrenia is increased
suspiciousness. Undifferentiated schizophrenia is
charactherized by increased halucinations and
delusions
Gan gan S
A client sttes that she hears Gods voice telling
her that she has sinned and needs to be
punished. Wich of the following nursing
diagnoses would be most appropriate?
1. Distrubed sensory perception related to guilt as evidanced by auditory

hallucinations

2. Social Isolation related to mistrust, as evidence by withdrawal behaviors

3. Distrubed thought processes relater to increased anxiety as evidenced by

delusional thinking

4. Impaired verbal communiccation related to disordered thinking as

evidenced by loose associations

Answer

(1) The client is describing an auditory hallucination

that is most likely related to unresolved guilt about a
perceived sin. Sosial isolation would be supported
by evidence indicating that the lientt refuses to come
out of her room. Distrubed thought processes would
be evidenced, for example, by the clients saying that
someone in her life is trying to punish her. Loose
associations are reflectionsof racing thoughts, not
problems with verbal communication
CARE OF PSYCHIATRIC

Created by :
Lela Karmila
When developing the plan care for a client
with suicidal ideation, which of the following
would the nurse anticipate as the priority?
A. Self-esteem
B. Sleep
C. Hygiene
D. safety
Answer D is correct

For the client with suicidal ideation, client

safety is the priority. The nurse protects
the client from self-harm or self-
destruction. Although self-esteem, sleep,
and hygiene are common areas that require
intervension for a client with suicidal
ideation, ensuring the clients safety is the
most immediate and serious consern.
THANKS FOR ATTENTION
NAME : FITRI YANI
NIM : 34403115041
 Which of the following statements by a client with delusions indicates to the
nurse that the client is improving?
A. I dont feel those crawling buys anymore
B. I wont talk about my crazy thoughts at work
C. I feel less jumpy inside
D. I must check my room for bugs
 RATIONAL
THE ANSWER IS B. Improvement in relation to delusional content includes
a reduction in the disturbing quality of the delusion and the clients ability to
control and/or not respond to them
A. This would indicate a respone to a tactile hallucination
C. This would not be a feature of delusions and may indicate agitation or
akathisia
D. This would indicate that the client is responding to a delusional belief that
is room is bugged