Page 2291 - Saunders Comprehensive Review For NCLEX-RN

with delusions may make the client more defensive, and the client may cling to the
delusions even more. Encouraging discussion regarding the delusion is
inappropriate.
Test-Taking Strategy: Note the strategic word, best. Use therapeutic
communication techniques. Eliminate options that show disagreement with the
client or encourage any discussion regarding the delusion.
Level of Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Communication and Documentation
Content Area: Mental Health
Health Problem: Mental Health: Therapeutic Communication
Priority Concepts: Communication; Psychosis
Reference: Varcarolis (2017), pp. 257-258.

804. Answer: 2

Rationale: Provision of a consistent daily routine and a low-stimulating
environment is important when a client is disoriented. Noise, including radio and
television, may add to the confusion and disorientation. Moving the client next to
the nurses’ station may become necessary but is not the initial action.
Test-Taking Strategy: Note the strategic word, initially. Eliminate options that are
inappropriate or premature actions and may increase stimulation and add to the
confusion. This will direct you to the correct option.
Level of Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Mental Health
Health Problem: Mental Health: Neurocognitive Impairment
Priority Concepts: Cognition; Safety
Reference: Varcarolis (2017), pp. 275, 277.

805. Answer: 4

Rationale: A client with depression often is withdrawn while experiencing
difficulty concentrating, loss of interest or pleasure, low energy, fatigue, and feelings
of worthlessness and poor self-esteem. The plan of care needs to provide successful
experiences in a stimulating yet structured environment. The remaining options are
either too “restrictive” or offer little or no structure and stimulation.
Test-Taking Strategy: Focus on the subject, the plan for a client with depression.
Recall that a depressed client requires a structured and stimulating program in a safe
environment. The correct option is the only one that will provide a safe and effective
environment.
Level of Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process—Planning
Content Area: Mental Health
Health Problem: Mental Health: Mood Disorders

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