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."

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A reason: Offering medication immediately does not address the client’s emotional state and undermines the use of therapeutic communication, which is the first-line intervention for moderate anxiety.

Choice B reason: This response is generic and educational, which is not appropriate in a crisis moment. The client needs immediate support and de-escalation.

Choice C reason: This response is inappropriate and harmful, suggesting a restraint that is not indicated and would likely worsen the client’s distress.

Choice D reason: This is the best therapeutic response. It provides a safe environment for the client to express feelings and decreases external stimuli, helping to reduce anxiety.

A. The client states, "I see purple bugs crawling on the wall." B. The client states, "My heart is pounding out of my chest." C. The client tells the nurse he is a government agent. D. The client tells the nurse that he is too tired to attend the group meeting.

Correct Answer is B

Explanation

Choice A reason:Seeing purple bugs crawling on the wall suggests visual hallucinations, a symptom of schizophrenia rather than anxiety. Alprazolam, a benzodiazepine, is prescribed for anxiety, not psychotic symptoms, which are better managed with antipsychotics.

Choice B reason:A pounding heart is a physical symptom of anxiety, indicating heightened arousal or panic. This aligns with the indication for alprazolam, which is used to relieve acute anxiety symptoms, making it appropriate to consider administering the medication.

Choice C reason:Claiming to be a government agent may reflect a delusion, a symptom of schizophrenia. Alprazolam is not indicated for delusions, which require antipsychotic treatment, so this statement does not warrant its use.

Choice D reason:Feeling too tired to attend a group meeting suggests fatigue, not necessarily anxiety. Alprazolam is not indicated for tiredness, which may require other interventions like rest or medical evaluation, making this an inappropriate trigger for administration.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse notices that a client who has moderate anxiety is pacing the hall and mumbling. As the nurse approaches the client, he states, "I am at the end of my rope. I don't think I can take any more bad news." Which of the following responses should the nurse make?

Correct Answer is D

Explanation

A nurse is caring for a client who has schizophrenia and generalized anxiety disorder. The client has a prescription for alprazolam 0.25 mg PO every 8 hr PRN anxiety. For which of the following client statements should the nurse consider administering alprazolam?

Correct Answer is B

Explanation

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