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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A. "I will do my best to avoid crying in front of my loved ones."
This statement suggests the client might be trying to hide their emotions, which can lead to further emotional distress. Suppressing emotions, like crying, is not a healthy coping mechanism and can exacerbate feelings of sadness and isolation.

B. “I will stay in bed on days when I feel exhausted."
Staying in bed excessively, especially during the day, is a behavior associated with depression and can worsen depressive symptoms. Encouraging the client to maintain a regular sleep schedule and engage in activities, even if they are small, is a more beneficial approach. Physical activity and exposure to natural light can positively impact mood.

C. “I’ll use the coping mechanisms that helped me in the past."
This is the correct choice. Reverting to previously effective coping mechanisms indicates an understanding of self-awareness and the ability to recognize what has worked positively in the past. Coping mechanisms such as relaxation techniques, hobbies, social support, or therapy can be valuable tools in managing depressive symptoms.

D. “I will avoid talking about events that upset me."
Avoiding discussions about upsetting events can prevent the client from addressing and processing their emotions, hindering the therapeutic process. Encouraging open communication and expressing feelings with a trusted individual, therapist, or support group can help the client work through emotional challenges.

A. Rambling speech B. Insomnia C. Rapid mood swings D. Sundowning

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.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

A nurse is providing teaching about self-care behaviors to a client who has major depressive disorder. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is C

Explanation

A nurse in a long-term care facility is assessing an older adult client for depression. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

A nurse is leading a critical incident stress debriefing with a group of staff members following a mass trauma incident. Which of the following Interventions should the nurse take first?

A nurse in a community mental health clinic is assessing a client who began taking lithium carbonate 5 days ago. The client reports fine hand tremors and has a current lithium level of 1.2 mEq/L. Which of the following actions should the nurse take?

A nurse in an emergency department is caring for a client following a domestic dispute. The client states, "Nothing seems to go right for me and probably never will." Which of the following statements should the nurse make?

A nurse is reviewing new prescriptions for a client who is experiencing acute manifestations of alcohol withdrawal. Which of the following medications should the nurse expect the provider to prescribe for this client?

A nurse is caring for a client who has major depressive disorder. After discussing the treatment with his partner, the client verbally agrees to electroconvulsive therapy (ECT) but will not sign the consent form. Which of the following actions should the nurse take?

A nurse is caring for a group of clients on a mental health unit. For which of the following clients is the nurse considered a mandated reporter to the appropriate agency?

A nurse is creating a plan of care for a client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan?