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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "Did you experience any childhood trauma?"
Childhood trauma, such as abuse or neglect, can contribute to various mental health conditions, including post-traumatic stress disorder (PTSD), depression, or anxiety disorders. While trauma can impact a person's mental health, it does not directly assess the risk for alcohol use disorder.
B. "Are you the result of a twin birth?"
Being a twin or the result of multiple births does not inherently indicate a risk for alcohol use disorder. This question is related to an individual's birth status and has no direct connection to the assessment of alcohol-related issues.
C. "Have you ever purposefully lost a job?"
This is the correct choice. Purposefully losing a job might indicate behavioral issues related to alcohol misuse or impairment. Individuals with alcohol use disorder may engage in behaviors that lead to job loss, such as absenteeism, poor performance, or conflict at the workplace due to alcohol consumption.
D. "Did your parent have a viral infection while pregnant with you?"
Prenatal viral infections can potentially affect fetal development and lead to certain health conditions. However, this question is not directly related to the risk of alcohol use disorder. Alcohol use disorder is primarily influenced by environmental factors, genetic predisposition, and individual behaviors related to alcohol consumption. Prenatal viral infections are not a typical indicator of alcohol-related concerns.
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.
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