A nurse is caring for a young adult client who has acute schizophrenic disorder and tells the nurse, "Yesterday noon the sun moon went over the rover to see the lawnmower.”. Which of the following manifestations is the client exhibiting?
Delusional disorder.
Anhedonia.
Associative looseness.
Hallucination.
The Correct Answer is C
Choice A rationale:
Delusional disorder is characterized by the presence of one or more delusions for a month or longer, which could be plausible but are not real. This is not the case here.
Choice B rationale:
Anhedonia refers to the inability to experience pleasure, a common symptom in many mental disorders, including depression. It does not apply to this situation.
Choice C rationale:
Associative looseness, or loose associations, is a thought disorder characterized by speech in which ideas shift from one subject to another that is unrelated or minimally related. The client’s statement is an example of this.
Choice D rationale:
Hallucinations are sensory experiences that occur in the absence of actual stimulation. The client’s statement is not a hallucination, but a disorganized thought process.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
A serum lithium level of 1.6 mEq/L is above the therapeutic range (0.6-1.2 mEq/L) and can cause symptoms such as GI discomfort and poor coordination.
Choice B rationale:
Lip smacking and tongue thrusting are not typically associated with lithium toxicity.
Choice C rationale:
While blurred vision can be a symptom of lithium toxicity, jerking motor movements are not typically associated with this condition.
Choice D rationale:
Fever and fluctuating blood pressure are not typically symptoms of lithium toxicity.
Correct Answer is C
Explanation
Choice A rationale:
A lithium level of 1.8 mEq/L is above the therapeutic level for initial treatment (0.8 to 1.4 mEq/L)3.
Choice B rationale:
A lithium level of 1.8 mEq/L is above, not below, the therapeutic treatment level.
Choice C rationale:
A lithium level of 1.8 mEq/L is at the toxic level. A blood lithium level greater than 1.5 mEq/L indicates toxicity.
Choice D rationale:
A lithium level of 1.8 mEq/L is not within the maintenance treatment level (0.4 to 1.3 mEq/L)3.
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