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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Recommend that the client participate in more solitary activities.
This option is not suitable because encouraging solitary activities may lead to further isolation, which can worsen the client's depressive feelings. Social support and connection are often crucial during the grieving process.
B. Explain to the client that the duration of grief is highly variable and can last for years.
This is the correct choice. Grief is a complex and individual process, and there is no specific timeline for how long it should last. Some people may continue to experience feelings of sadness and loss for an extended period after the death of a loved one. Validating the client's emotions and letting them know that their experience is within the range of normal can be comforting.
C. Encourage the client to avoid discussing the events surrounding the sibling's death.
This option is not recommended. Encouraging the client to avoid discussing their feelings can hinder the healing process. Open communication about the loss can help the client process their emotions and find ways to cope.
D. Caution the client against feeling angry at the sibling.
This option is not appropriate. Allowing the client to express their feelings, including anger, is a healthy part of the grieving process. Suppressing emotions, including anger, can lead to complications in the grieving process. It is essential to acknowledge and validate all the client's emotions.
Correct Answer is A
Explanation
A. Implement measures to prevent intentional self-inflicted injury:
This choice is the priority. Individuals with borderline personality disorder are at an increased risk of self-harm and suicidal behaviors. Implementing measures to prevent intentional self-inflicted injury, such as close monitoring, removing potentially harmful objects, and creating a safe environment, is crucial to ensuring the client's safety and well-being.
B. Discuss the appropriate use of assertive behavior with the client:
Teaching assertive behavior is an important aspect of therapy for individuals with borderline personality disorder. Learning to express emotions and needs in a healthy, assertive manner can improve their interpersonal skills and relationships. However, this choice is secondary to ensuring the client's safety. Safety concerns need to be addressed before moving on to other therapeutic interventions.
C. Encourage the client to attend weekly support group meetings:
Support group meetings can provide valuable social support and a sense of belonging for individuals with borderline personality disorder. Being part of a supportive community can offer understanding and coping strategies. While this is a beneficial intervention, it is not the priority. Safety concerns and addressing self-harm risk take precedence.
D. Assist the client to maintain awareness of her thoughts and feelings:
Developing self-awareness and emotional regulation skills is essential in managing borderline personality disorder. Techniques such as mindfulness and dialectical behavior therapy (DBT) can help individuals become more aware of their thoughts and emotions. While important for long-term management, this intervention is not the priority when immediate safety concerns are present. Safety should always be the first focus of care.
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