A nurse is caring for a client who has depression and states, "A government agency is attempting to capture me." The nurse should identify that the client is experiencing which of the following?
Inappropriate guilt
Mania
Delusions
Confusion
The Correct Answer is C
A. Inappropriate guilt is a common symptom of depression, but it does not involve false beliefs about being targeted. Clients with major depressive disorder may feel excessive guilt, but this differs from the fixed, false beliefs seen in delusions.
B. Mania is characterized by elevated mood, impulsivity, and hyperactivity rather than paranoid thoughts. While manic episodes may include grandiose delusions, the belief that a government agency is attempting to capture the client aligns more with persecutory delusions.
C. Delusions are fixed, false beliefs that persist despite evidence to the contrary. The client’s statement suggests a persecutory delusion, which is commonly seen in psychotic disorders, including severe depression with psychotic features.
D. Confusion involves disorganized thinking, memory impairment, or difficulty understanding surroundings, often seen in delirium or cognitive disorders. While delusions can contribute to disorganized thoughts, they are distinct from general confusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "Notify child protective services." Reporting to child protective services is only necessary if there is evidence of abuse, neglect, or an inability to provide adequate care. A diagnosis of borderline personality disorder alone does not warrant an automatic report.
B. "Suggest the children live with other relatives." Encouraging a client to relinquish custody without evidence of an inability to care for the children is not appropriate. Providing support and resources to enhance parenting skills is a more beneficial approach.
C. "Encourage the children to visit the psychiatric unit when the client is leaving." While family involvement is important, exposing young children to a psychiatric unit can be overwhelming and inappropriate. Alternative ways to support parent-child bonding should be considered.
D. "Offer the client information about a support group for parents." Support groups provide a structured environment for clients to share experiences, receive guidance, and develop coping strategies, which can help manage stress and improve parenting skills.
Correct Answer is D
Explanation
A. "Obsessive-compulsive disorder.": Obsessive-compulsive disorder (OCD) is more commonly associated with cluster C personality disorders, particularly obsessive-compulsive personality disorder, which involves rigid perfectionism and a preoccupation with orderliness.
B. "Schizophrenia.": Schizophrenia is not a common comorbidity of cluster B personality disorders. It is more closely linked to schizotypal personality disorder, a cluster A disorder, which involves eccentric behaviors and cognitive distortions.
C. "General anxiety disorder.": Generalized anxiety disorder (GAD) is more frequently seen in cluster C personality disorders, such as avoidant and dependent personality disorders, which are characterized by excessive fearfulness and anxiety-driven behaviors.
D. "Anorexia nervosa.": Anorexia nervosa is commonly comorbid with cluster B personality disorders, particularly borderline personality disorder, due to emotional dysregulation, impulsivity, and an intense fear of abandonment that can contribute to disordered eating behaviors.
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