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?

Derealization

Illusion

Hallucination

Depersonalization

Answer and Explanation

The Correct Answer is C

c. Hallucination

In the scenario described, the client's experience of receiving special audible messages from the Central Intelligence Agency that no one else can hear indicates a hallucination. Hallucinations are perceptual disturbances in which a person experiences sensory perceptions without any external stimuli. They can occur in any sensory modality, such as hearing (auditory hallucinations), seeing (visual hallucinations), smelling (olfactory hallucinations), tasting (gustatory hallucinations), or feeling (tactile hallucinations).

In this case, the client is experiencing auditory hallucinations, as he is perceiving auditory stimuli (audible messages) that are not present in the external environment. Auditory hallucinations are most commonly associated with schizophrenia, although they can occur in other psychiatric disorders as well.

Derealization (option a) refers to a subjective feeling of unreality or detachment from the environment. It involves a perception that the external world is strange, distorted, or unreal. This is not the primary alteration in perception described in the scenario.

Illusion (option b) is a misinterpretation or misperception of a real sensory stimulus. It occurs when a person's perception of an actual stimulus is distorted or misunderstood. There is no indication of a misperception of a real stimulus in the scenario.

Depersonalization (option d) is a subjective experience of being detached from one's own body, thoughts, or emotions. It involves a feeling of being outside of oneself or observing oneself from a distance. This is not the primary alteration in perception described in the scenario.

Therefore, the correct answer is c. Hallucination, as the client's experience of receiving special audible messages that no one else can hear represents an auditory hallucination.

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Correct Answer is D

Explanation

The nurse should identify that the newborn is making audible swallowing sounds as an indication that they are breastfeeding eﬀectively. This indicates that the newborn is able to latch onto the breast and transfer milk eﬀectively.

a) Falling asleep 5 minutes after starting a feeding may indicate that the newborn is not getting enough milk.

b) Having 3 wet diapers each day is not enough for a 5-day-old newborn. A newborn should have at least 6 wet diapers per day.

c) Having a bowel movement every other day is not an indication of eﬀective breastfeeding. A breastfed newborn should have at least 3 bowel movements per day.

A. Inject 20 units of air into the vial of NPH insulin. B. Inject 5 units of air into the vial of regular insulin. C. Withdraw 20 units of NPH insulin from the vial. D. Withdraw 5 units of regular insulin from the vial.

Correct Answer is A

Explanation

Answer: (A) Inject 20 units of air into the vial of NPH insulin.

Rationale:

A) Inject 20 units of air into the vial of NPH insulin:

Injecting air into the vial of NPH insulin is the first step to prevent creating a vacuum, which could make it difficult to withdraw the insulin later. The nurse must inject the corresponding amount of air for the dose needed, ensuring that the insulin can be withdrawn smoothly and accurately without bubbles, which could affect the dose.

B) Inject 5 units of air into the vial of regular insulin:

Injecting air into the regular insulin vial is also necessary before withdrawing the insulin, but it should be done after injecting air into the NPH vial. This sequence ensures that no NPH insulin contaminates the regular insulin vial when the nurse withdraws the doses later.

C) Withdraw 20 units of NPH insulin from the vial:

Withdrawing NPH insulin should be done after air is injected into both vials and after the regular insulin has been drawn up. This sequence prevents the mixing of the two types of insulin and ensures accurate dosing, which is crucial for maintaining the correct blood glucose levels.

D) Withdraw 5 units of regular insulin from the vial:

Withdrawing regular insulin is critical to do before the NPH insulin to prevent contamination of the regular insulin with NPH, which could alter the onset and peak times of the regular insulin. However, it should follow the steps of injecting air into both vials, starting with the NPH vial.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is breastfeeding their 5-day-old newborn. Which of the following should the nurse identify as an indication that the newborn is breastfeeding eﬀectively?

Correct Answer is D

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?

Correct Answer is A

Explanation

A nurse is assisting with developing a discharge plan for a client who has a new diagnosis of diabetes mellitus. The client is independent and lives alone. Which of the following interventions should the nurse plan to include?

A nurse in a pediatric clinic is reviewing the urine laboratory results for an adolescent. For which of the following results should the nurse notify the provider?

A nurse is reinforcing teaching with the parents of a preschool-age child who has a new diagnosis of celiac disease. Which of the following foods should the nurse recommend?

A nurse working on a mental health unit is meeting with a client who has been on the unit for 2 days. The nurse greets the client and asks, "What has been happening with you today?" Which of the following therapeutic techniques is the nurse using?

A nurse is reinforcing teaching with a parent about appropriate snacks for a toddler. Which of the following foods should the nurse include?

A nurse is preparing to administer a liquid medication to a 6-month-old infant who is crying. Which of the following actions should the nurse take to reduce the risk of aspiration?

A nurse is collecting data from a client who has a long-leg cast on his left leg and reports severe pain. Which of the following findings should the nurse identify as an indication that the client might have compartment syndrome? (Select all that apply.)

A nurse is collecting data from a client whose Hgb is 8.8 mg/dL. Which of the following statements should the nurse expect?