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 B
Explanation
Choice A rationale:
This statement is confrontational and may make the client defensive.
Choice B rationale:
This statement provides the client with a choice, promoting autonomy and encouraging self-care.
Choice C rationale:
This statement is forceful and does not respect the client’s autonomy.
Choice D rationale:
Ignoring the client’s lack of self-care does not address the issue and could potentially harm the client.
Correct Answer is A
Explanation
Choice A rationale:
Adherence to medication, especially after the resolution of acute psychosis, is crucial when taking an antipsychotic like clozapine. This is because discontinuation can lead to a relapse of symptoms.
Choice B rationale:
There’s no specific need to limit fluid intake when taking an antipsychotic.
Choice C rationale:
While routine blood cell count laboratory work is important, it’s not specific to red blood cells but rather to monitor for agranulocytosis, a potential side effect of clozapine.
Choice D rationale:
Avoiding foods that contain tyramine is typically associated with monoamine oxidase inhibitors, not antipsychotics like clozapine.
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