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. "I will take a stool softener to prevent constipation." This is correct. Postoperative clients, especially those who are on opioid medications for pain management, are at risk for constipation. Taking a stool softener is a good strategy to prevent this complication after surgery.
B. "I will ask to work the night shift, so I will not be driving in bright sunlight." This is incorrect. Following laser surgery for open-angle glaucoma, clients are typically advised to avoid bright lights and glare, but there is no need to change work schedules. The focus should be on wearing protective sunglasses to shield the eyes from sunlight and glare, not on avoiding daytime work hours.
C. "I will need to use my eye drops for 1 year." This is incorrect. While eye drops may be prescribed to manage intraocular pressure, the duration of use will depend on the specific medication and the client's condition. It is not typically necessary to use them for an entire year after laser surgery, and the client should follow the provider's instructions for tapering or stopping the medication as indicated.
D. "I will need to follow a low-protein diet." This is incorrect. There is no specific dietary restriction for a low-protein diet following laser surgery for open-angle glaucoma. The client should follow a balanced diet as recommended by the healthcare provider.
Correct Answer is B
Explanation
A. Constipation is not a common or serious adverse effect of cefazolin and typically does not require provider notification.
B. Elevated skin patches may indicate an allergic reaction or a more severe hypersensitivity response, such as a rash or urticaria. This requires prompt reporting to the provider to prevent progression to more serious reactions like anaphylaxis.
C. Ringing in the ears (tinnitus) is associated with ototoxic medications, not cefazolin, and is not a typical adverse effect of this antibiotic.
D. Depression is not linked to cefazolin use and is not a side effect the adolescent needs to monitor in this context.
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