A nurse is assessing a client who has schizophrenia. The client tells the nurse. "My heart exploded and my blood is draining out." The nurse should interpret this statement as which of the following manifestations?

Paranoia

A somatic delusion

Concrete thinking

A visual hallucination

Answer and Explanation

The Correct Answer is B

A. Paranoia:
Paranoia involves unfounded beliefs that others are plotting against, persecuting, or harming the individual. It is not directly related to the client's statement about bodily sensations.

B. A somatic delusion:
This is the correct choice. A somatic delusion is a false belief related to the body. In this case, the client believes that their heart exploded and blood is draining out, which is a somatic delusion involving bodily functions and sensations.

C. Concrete thinking:
Concrete thinking refers to a literal and straightforward way of thinking without the ability to interpret abstract or metaphorical language. While the client's statement is literal, it is not an example of concrete thinking. Concrete thinking would involve an inability to understand figurative language, which is not the case here.

D. A visual hallucination:
Visual hallucinations involve seeing things that are not present. The client's statement does not describe a visual experience but rather a false belief about bodily sensations, indicating a somatic delusion.

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Correct Answer is A

Explanation

A. Suppression:
Suppression is a psychological defense mechanism where an individual consciously avoids thinking about certain thoughts, emotions, or impulses. It involves intentionally putting aside disturbing or anxiety-inducing thoughts temporarily. People use suppression as a way to cope with overwhelming emotions or stressful situations by delaying dealing with them until they feel more prepared.

B. Regression:
Regression is a defense mechanism where an individual reverts to a previous stage of development in the face of stressful situations. For example, an adult may exhibit childlike behaviors or emotions during times of high stress. This regression is an unconscious way of seeking comfort and security from an earlier, less stressful time in life.

C. Compensation:
Compensation is a defense mechanism in which an individual tries to make up for a perceived deficiency in one area by excelling in another. For instance, someone who feels unattractive might compensate by becoming exceptionally skilled in a particular talent. Compensation involves overachieving in one area to cover up feelings of inadequacy in another.

D. Sublimation:
Sublimation is a defense mechanism where socially unacceptable impulses or urges are channeled into socially acceptable and productive activities. For example, someone with aggressive tendencies might channel their aggression into sports or artistic pursuits. Sublimation involves transforming negative emotions or desires into positive, socially acceptable behaviors.

A. Monitor the client's sodium levels. B. Evaluate the client's frequency of panic attacks. C. Inform the client that application site rash is common. D. Observe the client for 3 hr following administration of medication.

Correct Answer is D

Explanation

A. Monitor the client's sodium levels:
This action is not directly related to the administration of olanzapine. Olanzapine does not typically affect sodium levels directly. Monitoring sodium levels is essential for some other medications or conditions, but it is not a specific consideration for olanzapine administration.

B. Evaluate the client's frequency of panic attacks:
Evaluating the frequency of panic attacks is not directly related to the administration of olanzapine. Olanzapine is an antipsychotic medication used to treat conditions like schizophrenia and bipolar disorder. It is not primarily indicated for the treatment of panic attacks. Monitoring panic attacks would be relevant if the client's primary concern was panic disorder, but it's not the priority in this scenario.

C. Inform the client that application site rash is common:
This information is not relevant to the administration of olanzapine in the form of an intramuscular injection. Application site rash is a concern for topical medications or transdermal patches, not for IM injections. Therefore, informing the client about application site rash is not necessary in this context.

D. Observe the client for 3 hours following the administration of medication:
This is the correct action. Olanzapine extended-release IM injection requires close observation for at least 3 hours after administration. This monitoring period is essential due to the potential risk of post-injection delirium/sedation syndrome, which can occur shortly after the injection. Monitoring allows for the early detection of any adverse reactions, ensuring the client's safety and well-being.

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A nurse is assessing a client who has schizophrenia. The client tells the nurse. "My heart exploded and my blood is draining out." The nurse should interpret this statement as which of the following manifestations?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A nurse is preparing to administer olanzapine extended release 210 mg IM to a client. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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