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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
c. Ketones positive.
Explanation:
Ketones in the urine can be an indication of diabetic ketoacidosis (DKA) or other metabolic disorders. It is abnormal and should be reported to the healthcare provider for further evaluation and management. Positive ketones suggest that the body is breaking down fats for energy instead of using glucose, which can be a sign of inadequate insulin levels or utilization.
Options a, b, and d are within normal ranges or do not indicate an immediate concern. A specific gravity of 1.020 is within the normal range and indicates appropriate urine concentration. Uric acid levels of 475 mg/24 hr are not mentioned as abnormal or concerning in the context provided. Nitrites negative indicates the absence of nitrites in the urine, which is a normal finding and indicates the absence of a urinary tract infection.
However, it's important to note that clinical judgment should always be exercised, and the nurse should consider the patient's overall clinical presentation and history when interpreting laboratory results and making decisions regarding reporting to the provider.
Correct Answer is C
Explanation
c. "I will have a chest x-ray following the procedure."
Explanation:
The statement that indicates an understanding of the information provided is "I will have a chest x-ray following the procedure."
Explanation for the other options:
a. "I will have general anesthesia during the procedure":
This statement is incorrect. Thoracentesis is typically performed using local anesthesia, which numbs the area where the needle will be inserted. General anesthesia, which induces a state of unconsciousness, is not usually required for this procedure.
b. "I will lie flat for 6 hours following the procedure":
This statement is incorrect. While the client may be advised to lie still for a short period after the thoracentesis, it is not necessary for them to lie flat for a full 6 hours. The specific post-procedure instructions may vary depending on the client's condition and the healthcare provider's preferences.
d. "I will breathe deeply through my nose during the procedure":
This statement is incorrect. During a thoracentesis, the client is typically asked to sit upright and lean forward to allow beter access to the space between the lungs and chest wall. They may be instructed to take slow, deep breaths and hold their breath for short periods as needed during the procedure to help maintain proper positioning and reduce the risk of complications.
In summary, the statement that demonstrates an understanding of the thoracentesis procedure is "I will have a chest x-ray following the procedure." This indicates the client's awareness of the need for a post- procedure chest x-ray to evaluate the results and ensure the absence of any complications.
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