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 B
Explanation
A. "Do you think of yourself as more of an introvert? That makes a difference with how you socialize." Social withdrawal in schizophrenia is not related to personality traits like introversion. It is often an early symptom of the disorder, preceding more pronounced psychotic features. Focusing on introversion may mislead the client and overlook the underlying pathology.
B. "Before symptoms of schizophrenia begin, people often isolate themselves. This is an early warning." Social withdrawal is a common early sign of schizophrenia, occurring during the prodromal phase. Individuals may withdraw due to subtle cognitive changes, emotional blunting, or emerging paranoid thoughts. Recognizing these early symptoms can aid in early intervention and treatment.
C. "Were you avoiding your friend so that you could hear the voices more clearly?" This statement assumes the client was already experiencing auditory hallucinations, which is not always the case. Social isolation often predates the onset of hallucinations and delusions, making this explanation inaccurate. It may also come across as dismissive rather than informative.
D. "That is very interesting, We are not sure why people start to isolate themselves." While the exact cause of social withdrawal in schizophrenia is not fully understood, research indicates it is an early warning sign. Providing vague or uncertain information may leave the client feeling confused rather than supported in understanding their condition.
Correct Answer is D
Explanation
A. "Lately, I feel like I am more alert than usual and can focus better.": Depression is commonly associated with difficulties in concentration, memory impairment, and slowed cognitive function rather than increased alertness or improved focus. Clients with depression often report feeling mentally sluggish or experiencing brain fog.
B. "I can't sit still. I feel like I need to be doing things around the house.": While some individuals with depression experience psychomotor agitation, it is more common for depression to present with fatigue, low energy, and decreased motivation. Restlessness may also be seen in anxiety disorders, but it is not a primary symptom of depression.
C. "When I went to my provider, they told me I have high blood pressure.": Hypertension is a medical condition that may have various causes, but it is not a direct manifestation of depression. However, chronic stress and depression can contribute to cardiovascular issues over time, though depression itself is primarily characterized by emotional and cognitive symptoms.
D. "I can't get my mind to stop racing at night. I'm only sleeping a couple of hours.": Insomnia and difficulty falling or staying asleep are hallmark symptoms of depression. Clients often experience ruminative thoughts, early-morning awakenings, or non-restorative sleep, which can contribute to worsened mood, fatigue, and impaired daily functioning.
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