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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Providing a tour of the perioperative area prior to surgery helps familiarize the adolescent with the environment, reducing anxiety and promoting a sense of control over the situation.
B. Explaining that anesthesia is a special type of sleep is oversimplifying and may not provide the adolescent with a clear understanding of the procedure. It's important to provide accurate information at a developmentally appropriate level.
C. Waiting until after surgery to explain the importance of coughing and deep breathing misses an opportunity for preoperative education. Teaching about postoperative care beforehand allows the adolescent to understand and participate in their own recovery process.
D. Keeping medical equipment out of the client's sight may reduce anxiety, but it does not address the adolescent's need for preparation and education about the surgical experience.
Correct Answer is B
Explanation
A. Massaging around the edge of the cast with lotion can lead to skin breakdown and should be avoided.
B. Elevating the extremity helps reduce swelling, promotes venous return, and decreases the risk of complications such as compartment syndrome.
C. Instructing the client to insert objects under the cast is unsafe and can cause skin injury or infection.
D. Numbness in the toes is not expected; it can indicate impaired circulation or nerve damage and should be reported immediately.
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