A nurse is reading the medical record for a client who has schizophrenia, which indicates that the client exhibits depersonalization. Which of the following statements by the client confirms that she is experiencing depersonalization?
"Everything in this room has changed and I don't recognize it anymore."
"I hear voices telling me that I have been bad."
"I have broken off all my past relationships because my friends and family are trying to kill me."
"My hands and feet are much smaller than they used to be."
The Correct Answer is D
Choice A reason: This statement reflects derealization, which is the experience that the external environment feels unreal or changed, not depersonalization.
Choice B reason: This describes auditory hallucinations, a common symptom of schizophrenia, but not depersonalization.
Choice C reason: This indicates persecutory delusions, not depersonalization.
Choice D reason: This confirms depersonalization, which involves altered perception of one’s own body or sense of self, such as believing body parts are distorted in size or shape.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:Vomiting or diarrhea can lead to dehydration, which increases lithium levels in the blood, potentially causing toxicity. Instructing the client to notify their provider about these symptoms is critical for safe lithium use.
Choice B reason:Decreasing fluid intake to 1 liter per day is dangerous with lithium, as adequate hydration (typically 2–3 liters daily) is needed to prevent toxicity. This is incorrect advice.
Choice C reason:Excessive saliva is not a common side effect of lithium. More typical side effects include thirst, tremor, or weight gain, so this statement is inaccurate.
Choice D reason:Lithium can be taken with or without food, but taking it with food may reduce stomach upset. Advising it must be taken on an empty stomach is not necessary and could discourage adherence.
Correct Answer is D
Explanation
Choice A reason:Citing personal reasons, such as needing to get home to family, is unprofessional and shifts focus away from the client’s needs. It does not address the client’s request or provide a constructive solution, making it an inappropriate response.
Choice B reason:Offering to do whatever the nurse can to help is vague and could imply willingness to perform prohibited tasks like shopping. This response risks crossing professional boundaries and is not appropriate.
Choice C reason:Suggesting the client wait for days when they feel better dismisses their current fatigue and inability to shop. It fails to offer immediate support or solutions, which is not helpful for an older adult needing assistance.
Choice D reason:Proposing to explore other resources, such as community services or family support, is appropriate because it respects the nurse’s professional boundaries while addressing the client’s needs. This response empowers the client by connecting them with sustainable solutions.
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