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 ["90"]
Explanation
To find out how many mL the nurse should administer for the total daily dose, we need to calculate the total daily dose and then convert it to mL using the available concentration.
The client is prescribed hydroxyzine 60 mg PO every 8 hours. To find the total daily dose, we can first calculate the dose per day and then convert it to mL.
Dose per day = Dose per dose interval x Number of doses per day
Dose per day = 60 mg x 3 (every 8 hours)
Dose per day = 180 mg per day
Now, we need to convert this dose to mL using the available concentration:
Concentration: 10 mg/5 mL
To find out how many mL for 180 mg, we can set up a proportion:
(10 mg / 5 mL) = (180 mg / x mL)
Cross-multiply:
10 mg * x mL = 5 mL * 180 mg
Now, solve for x (the number of mL):
x mL = (5 mL * 180 mg) / 10 mg
x mL = 900 mL / 10 mg
x mL = 90 mL
So, the nurse should administer 90 mL for the total daily dose.
Correct Answer is B
Explanation
A. Rambling speech
Rambling speech is not a typical finding associated with depression. It may indicate other conditions or issues.
B. Insomnia
Insomnia, or difficulty sleeping, is a common symptom of depression. Many individuals with depression experience trouble falling asleep, staying asleep, or both.
C. Rapid mood swings
Rapid mood swings are not typically associated with depression. Depression often involves persistent low mood rather than rapid fluctuations.
D. Sundowning
Sundowning refers to a state of confusion and restlessness that occurs in the late afternoon and evening, often seen in individuals with dementia. While it can be related to mood disturbances, it's not specific to depression.
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