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 response acknowledges the daughter's feelings without making assumptions or placing blame, fostering open communication and understanding within the family group.
B. This response may escalate the daughter's anxiety and is not directly related to her statement about causing her mother's depression.
C. This response may inadvertently encourage the daughter to blame herself for her mother's depression, which is not helpful in addressing family dynamics.
D. This response may put the daughter on the spot and could make her feel defensive or misunderstood, hindering effective communication within the family group.

A. Ignore the nonverbal behavior and focus on the client's verbal messages. B. Integrate the verbal and nonverbal messages and interpret them as one. C. Ask the client's spouse to interpret the discrepancy. D. Pay close attention and document the nonverbal messages.

Correct Answer is D

Explanation

A. Ignoring nonverbal behavior may overlook important cues that could provide valuable insight into the client's condition and needs.
B. Integrating verbal and nonverbal messages is important, but it may not address the discrepancy or the potential significance of the nonverbal cues.
C. Asking the client's spouse to interpret the discrepancy may not be appropriate or effective, as the spouse may not fully understand the client's nonverbal cues or their significance.
D. Paying close attention and documenting nonverbal messages allows the nurse to gather comprehensive data and potentially explore the observed discrepancy further in subsequent interactions or assessments.

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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

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Correct Answer is A

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Correct Answer is D

Explanation

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