A nurse is assisting with an admission interview for a client who has schizophrenia. He tells the nurse that he is receiving special audible messages from the Central Intelligence Agency that no one else is able to hear. The nurse should identify that the client is having which of the following alterations in perception?

Depersonalization

Hallucination

Illusion

Derealization

Answer and Explanation

The Correct Answer is B

A.   Depersonalization is a feeling of detachment from oneself or feeling like one's thoughts, feelings, and actions are not their own. It does not involve perceptual disturbances such as hearing voices.
B.   Hallucination is a sensory perception that occurs in the absence of external stimuli. Auditory hallucinations involve hearing voices or sounds that others do not hear, as described by the client in this scenario.
C.   Illusion is a misinterpretation of a sensory stimulus that is actually present in the environment. It involves a distortion or misperception of sensory information, not the perception of something that is not there, as in the case of hallucinations.
D.   Derealization is a feeling of unreality or detachment from one's surroundings. It involves a distortion in the perception of the external world rather than sensory experiences such as hearing voices.

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Correct Answer is C

Explanation

A. Incorrect. Prazosin is an alpha-adrenergic blocker used to treat hypertension and does not typically require a reversal agent in this situation.
B. Incorrect. While prazosin can cause orthostatic hypotension, initiation of cardiac monitoring is not typically necessary unless there are additional signs or symptoms of cardiovascular instability.
C. Correct. Prazosin can cause orthostatic hypotension, so instructing the client to stand up slowly can help prevent falls and minimize symptoms of dizziness or lightheadedness.
D. Incorrect. While prazosin can cause urinary retention, the client's blood pressure is low, suggesting hypotension rather than urinary retention as the primary concern. Therefore, instructing the client to report urinary retention is not the most appropriate action in this scenario.

A. Restrict the client's fluid intake. B. Keep suction equipment at the client's bedside. C. Instruct the client to look down when ambulating. D. Position the client supine after eating.

Correct Answer is B

Explanation

A. Restricting the client's fluid intake is not appropriate for Parkinson's disease management.

Adequate hydration is important to prevent complications such as constipation and urinary tract infections.
B. Keeping suction equipment at the client's bedside is important because Parkinson's disease can affect swallowing and increase the risk of aspiration. Having suction equipment readily available can help manage secretions and prevent aspiration pneumonia.

C. Instructing the client to look down when ambulating is not specifically related to Parkinson's disease management. Instead, clients with Parkinson's disease may benefit from visual cues and strategies to improve balance and mobility.
D. Positioning the client supine after eating is not recommended, as it may increase the risk of aspiration. Clients with Parkinson's disease may benefit from remaining upright after meals to facilitate digestion and reduce the risk of aspiration.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving prazosin. The client's blood pressure is 100/60 mm Hg. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is contributing to the plan of care for a client who has Parkinson's disease. Which of the following interventions should the nurse plan to include?

Correct Answer is B

Explanation

A nurse is preparing to administer 5 units of regular insulin and 20 units of NPH insulin to a client who has type 1 diabetes mellitus. Which of the following actions should the nurse take first?

A nurse is assisting with the care of a client who is in active labor. Which of the following data is the priority for the nurse to collect following an amniotomy?

A nurse is assisting in the development of an in-service for staff members about physical abuse of children. Which of the following children are at an increased risk for physical abuse?

A nurse is collecting data from a client who has substance use disorder and reports recently taking opioids. Which of the following findings should the nurse identify as a manifestation of opioid intoxication?

A nurse is reinforcing teaching with a client who plans to bottle feed her newborn. Which of the following statements indicates an understanding of the instructions?

A nurse is caring for a newborn following a circumcision. Which of the following manifestations indicates the newborn is experiencing pain?

A charge nurse is explaining the role of a licensed practical nurse to an assistive personnel (AP). Which of the following responsibilities should the charge nurse include?

A nurse is reinforcing discharge teaching about limiting sodium intake with a client who has a new diagnosis of cardiomyopathy. Which of the following client responses indicates an understanding of the teaching?