Mr. S states, "Look at the snakes on the ceiling!" You see some cracks in the plaster. Mr. S is experiencing a/an:
Illusion
Flashback
Hallucination
Delusion
The Correct Answer is A
Choice A reason: An illusion is a misinterpretation of a real external stimulus. Mr. S is mistaking the cracks in the plaster for snakes, which is an illusion.
Choice B reason: A flashback is a vivid memory of a traumatic event that feels like it is happening again. This does not describe Mr. S's experience.
Choice C reason: A hallucination is a sensory experience of something that does not exist outside the mind. Since Mr. S is misinterpreting an actual visual stimulus (the cracks), it is not a hallucination.
Choice D reason: A delusion is a firmly held false belief resistant to reason or confrontation with actual fact. Mr. S's belief is based on a misinterpretation of a visual stimulus, not a delusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Coughing and deep breathing exercises after surgery are encouraged to prevent atelectasis, which is the collapse of part or (less commonly) all of a lung.
Choice B reason: Induction is not a postoperative complication; it refers to the process of initiating anesthesia.
Choice C reason: Hypothermia is a condition of abnormally low body temperature, not directly prevented by coughing and deep breathing.
Choice D reason: Hematoma, a collection of blood outside of blood vessels, is not prevented by coughing and deep breathing exercises.
Correct Answer is D
Explanation
Choice A: "I’m sorry if I upset you. I just wanted to make sure you’re aware of the day’s schedule."
This response may seem empathetic, but it could potentially reinforce the client's aggressive behavior. The nurse is apologizing, which might give the impression that the client's rude behavior is acceptable¹.
Choice B: "Well, if you can read it yourself, then why don’t you?"
This response is confrontational and could escalate the situation. It's important for the nurse to maintain a neutral and respectful manner.
Choice C: "You don’t have to be so rude. I’m just doing my job."
This response is defensive and could provoke further aggression from the client. It's not recommended to respond defensively to clients with borderline personality disorder¹.
Choice D: "I didn’t mean to offend you. I’ll leave the schedule here for you to review."
This is the most appropriate response. The nurse acknowledges the client's feelings without reinforcing the aggressive behavior. The nurse also respects the client's autonomy by leaving the schedule for the client to review¹.
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