A nurse learns at report that a newly admitted client experiencing mania is demonstrating grandiose delusions. The nurse should recognize which client statement would provide supportive evidence of this symptom?
I'm the world's most perceptive attorney.
The FBI is out to get me
I can't stop my sexual urges. They have led me to numerous affairs.
My wife is distraught about my overspending
The Correct Answer is A
A. "I'm the world's most perceptive attorney.": This statement reflects grandiosity, a common feature of grandiose delusions. The client is expressing an exaggerated belief in their own importance and abilities, indicating a distorted perception of reality.
B. "The FBI is out to get me": This statement suggests paranoid delusions, where the client believes they are being persecuted or conspired against. It does not specifically indicate grandiose delusions.
C. "I can't stop my sexual urges. They have led me to numerous affairs": This statement reflects impulsivity and hypersexuality, which are common features in manic episodes but do not specifically indicate grandiose delusions.
D. "My wife is distraught about my overspending": This statement reflects a consequence of manic behavior (overspending) but does not directly indicate grandiose delusions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Incorrect. Mental health and mental illness are not the same concepts. Mental health refers to a person's emotional, psychological, and social well-being, while mental illness refers to specific mental health conditions that significantly affect a person's thoughts, emotions, and behaviors.
B. Incorrect. Mental health and mental illness can both present at any age. Mental health is a broader concept that encompasses overall well-being, while mental illnesses can manifest at various stages of life.
C. Correct. This statement accurately distinguishes between mental health and mental illness. Mental health involves the ability to cope with daily stressors, while mental illness is characterized by disruptions in activities of daily living due to specific mental health conditions.
D. Incorrect. This statement confuses the relationship between mental health and mental illness. Mental health is a broader concept that contributes to overall well-being, while mental illness is a specific condition that may arise due to various factors, including poor mental health.
Correct Answer is D
Explanation
A. Implement the client's behavioral modification plan:
While addressing the client's behavioral modification plan is important, it may not be the immediate priority when the client has self-inflicted cuts. Ensuring physical safety and assessing the extent of the injury take precedence.
B. Document the size and location of the cuts:
Documentation is important, but it is not the first action to be taken. The immediate concern is to assess the physical condition of the cuts and address any potential risks.
C. Administer a tetanus antitoxin:
Administering a tetanus antitoxin may be necessary depending on the nature and depth of the cuts. However, it is not the first action. First, a thorough inspection of the cuts is needed to determine the appropriate course of action.
D. Inspect the cuts for debris:
This is the most appropriate first action. Inspecting the cuts for debris helps determine the severity of the wounds and whether there is a risk of infection. It also allows the nurse to assess the need for further medical intervention.
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