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. A client who has a new onset of chest pain B. A client who has a tracheostomy C. A client who is receiving enteral feedings D. A client who has urinary retention

Correct Answer is A

Explanation

The nurse should identify that caring for a client who has a new onset of chest pain is outside the scope of practice for an LPN. This is a complex and potentially life-threatening situation that requires the assessment and intervention of a registered nurse (RN) or other advanced practice provider.

b) Caring for a client who has a tracheostomy is within the scope of practice for an LPN.

c) Caring for a client who is receiving enteral feedings is within the scope of practice for an LPN.

d) Caring for a client who has urinary retention is within the scope of practice for an LPN.

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Nursing Test Bank

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 reviewing client care assignments prior to the beginning of a shift. Which of the following client assignments should the nurse identify as being outside the scope of practice for an LPN?

Correct Answer is A

Explanation

A nurse is providing change-of-shift report for a client who has heart failure. Which of the following information should the nurse notinclude in the report?

A nurse is assessing the visual acuity of a client who wears glasses using a Snellen chart. Which of the following actions should the nurse take?

A nurse is reinforcing teaching with a school-age child who has hemophilia about participating in school sports. Which of the following sports should the nurse recommend for the child? (Select all that apply.)

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 caring for a client who is near death. Which of the following actions should the nurse take?

A nurse is collecting data from a client who has hyponatremia. Which of the following findings should the nurse expect?

A nurse is collecting data from a client who has a gastrostomy tube and is experiencing diarrhea. Which of the following factors should the nurse identify as a potential cause of the diarrhea?

A nurse is reinforcing teaching with a client who is taking allopurinol about the risk for developing Stevens-Johnson syndrome. For which of the following manifestations should the nurse instruct the client to monitor and report?