A nurse is caring for a client diagnosed with schizophrenia. The client states, "Did you know that I am engaged to the Prince of England?" The nurse should document that the client is experiencing which of the following types of delusions?
Persecution.
Erotomanic.
Somatic.
Control.
The Correct Answer is B
The correct answer is choice B. Erotomanic.
Choice A rationale:
Persecution. Persecutory delusions involve the belief that one is being targeted, harmed, or conspired against by others. This choice is not applicable in this scenario because the client is not expressing fear or belief that they are being persecuted.
Choice B rationale:
Erotomanic. Erotomanic delusions involve the false belief that someone, often of higher social status, is in love with the individual. In this case, the client's statement about being engaged to the Prince of England suggests an erotomanic delusion. The client is holding a grandiose belief that they are romantically involved with someone of prominence.
Choice C rationale:
Somatic. Somatic delusions involve the belief that there is something physically wrong with the individual's body. These delusions often manifest as the belief in having an illness or defect that is not actually present. The client's statement does not revolve around physical health or bodily concerns, making somatic delusion an unlikely option.
Choice D rationale:
Control. Control delusions involve the belief that one's thoughts, feelings, or actions are being controlled by external forces. This choice is not applicable in this scenario, as the client's statement does not indicate any perceived loss of control over their thoughts or actions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E"]
Explanation
The correct answers are: a. Delayed language development, c. Spinning a toy repetitively, and e. Ritualistic behavior.
Explanation:
Choice A Rationale: Delayed language development is a common characteristic of autism spectrum disorder (ASD). Children with ASD may exhibit difficulties in acquiring and using language appropriately, including delayed onset of speech, limited vocabulary, and challenges with syntax and pragmatics. This delay can significantly impact their ability to communicate effectively and engage in social interactions. Early intervention strategies, such as speech therapy and alternative communication methods, are often implemented to support language development in children with ASD.
Choice B Rationale: Consistent limit testing, characterized by challenging authority and testing boundaries, is not a hallmark feature of autism spectrum disorder (ASD). While some children with ASD may exhibit behaviors that appear oppositional or defiant, such behaviors are more commonly associated with other conditions such as oppositional defiant disorder (ODD) or conduct disorder (CD). ASD is primarily characterized by deficits in social communication and interaction, along with restricted, repetitive patterns of behavior, interests, or activities.
Choice C Rationale: Spinning a toy repetitively is a stereotypical behavior often observed in children with autism spectrum disorder (ASD). Repetitive behaviors, including spinning objects, rocking back and forth, or hand-flapping, are considered one of the core diagnostic criteria for ASD. These behaviors serve various functions for individuals with ASD, including sensory stimulation, self-soothing, or reducing anxiety. While repetitive behaviors can vary widely among individuals with ASD, they are a recognizable feature of the disorder.
Choice D Rationale: A short attention span is not a specific characteristic of autism spectrum disorder (ASD). While some children with ASD may exhibit difficulties with attention and focus, particularly in tasks that do not align with their specific interests or preferences, attention deficits are not universal among individuals with ASD. Additionally, attention difficulties are not considered a primary diagnostic criterion for ASD. Other neurodevelopmental disorders, such as attention-deficit/hyperactivity disorder (ADHD), are more commonly associated with impairments in attention and concentration.
Choice E Rationale: Ritualistic behavior, such as engaging in specific routines or repetitive actions, is a hallmark feature of autism spectrum disorder (ASD). Children with ASD often demonstrate a preference for predictability and sameness in their environment, leading to the development of rigid routines or rituals. These behaviors can serve as a source of comfort or security for individuals with ASD, providing structure and predictability in an otherwise unpredictable world. Ritualistic behaviors can manifest in various forms, such as insisting on following the same daily schedule, arranging objects in a specific order, or becoming distressed when routines are disrupted.
Correct Answer is B
Explanation
Choice A rationale:
Telling the newly diagnosed cancer clients that they need to work hard on resolving conflicts with those closest to them may come across as insensitive and dismissive of their emotional struggles. Cancer diagnosis often brings about complex emotions, and this response does not acknowledge or address their concerns.
Choice B rationale:
This response acknowledges the client's statement and encourages further discussion about their feelings regarding their inability to return to work. It shows empathy and a willingness to explore their concerns, promoting open communication and emotional support.
Choice C rationale:
Commenting on the client's physical behavior without context might make them uncomfortable or self-conscious. The nurse's observation about fist clenching should be addressed more delicately if relevant, and the focus should be on the emotional aspect rather than the physical behavior.
Choice D rationale:
Dismissing the potential benefit of antidepressants and promoting the therapy group might undermine the client's feelings and choices. While group therapy can be beneficial, this response overlooks the potential need for a multifaceted approach to treatment, which could include therapy and medication.
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