The nurse documents that a client with schizophrenia is delusional. Which statement by the client confirms this assessment?

"The snakes on the wall are going to eat me."

"The nurse at night is trying to poison me with pills."

"The voices are telling me to kill the next person I see."

"The fire is burning my skin away right now."

None

Answer and Explanation

The Correct Answer is B

A. "The snakes on the wall are going to eat me." describes a visual hallucination, not a delusion. Hallucinations involve false sensory perceptions, such as seeing things that are not present. While hallucinations are common in schizophrenia, this statement does not indicate a delusion.

B. "The nurse at night is trying to poison me with pills." confirms a delusion, specifically a paranoid delusion. Delusions are fixed, false beliefs that are not based in reality and cannot be changed by logic or reasoning. In this case, the client irrationally believes that the nurse is trying to harm them, which is a classic symptom of schizophrenia.

C. "The voices are telling me to kill the next person I see." describes an auditory hallucination, which involves hearing voices or sounds that are not real. While auditory hallucinations are a common symptom of schizophrenia, this statement does not indicate a delusion.

D. "The fire is burning my skin away right now." describes a tactile hallucination, where the client falsely perceives sensations (e.g., burning). This is another form of hallucination, not a delusion, as it involves sensory misperception rather than a false belief.

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Correct Answer is A

Explanation

A. This comment acknowledges the client's behavior without making assumptions or judgments about the content of the hallucinations. It validates the client's experience and opens the door for further discussion if the client wishes to share more about what they are experiencing.
B. This comment does not directly address the client's current experience and may not be as helpful in validating the client's reality.
C. This comment focuses on redirecting the client's attention rather than acknowledging their experience, which may not be as therapeutic in this context.
D. This comment may invalidate the client's experience by directly contradicting their perception of reality. It is important to avoid dismissing or denying the client's experiences without further assessment and understanding.

A. Current vital signs. B. White blood cell count. C. 24-hour urinary output. D. Blood sugar level.

Correct Answer is A

Explanation

A. Current vital signs are essential for assessing for neuroleptic malignant syndrome (NMS), a potentially life-threatening side effect of antipsychotic medications like haloperidol. Vital signs such as temperature, blood pressure, heart rate, and respiratory rate are crucial indicators of
NMS.

B. While monitoring white blood cell count may be important for detecting infections or adverse reactions to medications, it is not specific to assessing for NMS.
C. Monitoring 24-hour urinary output may be important for assessing renal function but is not specific to assessing for NMS.
D. Monitoring blood sugar levels may be important for clients with diabetes or those at risk of hyperglycemia due to medication effects, but it is not specific to assessing for NMS.

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The nurse documents that a client with schizophrenia is delusional. Which statement by the client confirms this assessment?

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Naxlex Comprehensive Predictor Exams

The nurse observes a client with a history of psychosis repeatedly looking to the side and mumbling responses to no one present in that direction. Which comment is best for the nurse to make?

Correct Answer is A

Explanation

A client with schizophrenia returns to the clinic two weeks after receiving a prescription for haloperidol. To assess for neuroleptic malignant syndrome (NMS), which information is most important for the nurse to obtain during this visit?

Correct Answer is A

Explanation

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