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
None
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Responding with illogical answers to questions is characteristic of schizophrenia, particularly during periods of psychosis when the client may experience disorganized thinking and impaired reality testing.
B. Admitting to frequently thinking about committing suicide is not specific to schizophrenia and may occur in various mental health conditions, such as depression or bipolar disorder.
C. Describing times of depression followed by feelings of euphoria suggests a mood disorder, such as bipolar disorder, rather than schizophrenia.
D. Exhibiting compulsive, ritualistic behaviors may be seen in obsessive-compulsive disorder (OCD) but is not typically characteristic of schizophrenia. Schizophrenia is primarily characterized by positive symptoms (such as hallucinations and delusions), negative symptoms (such as blunted affect and social withdrawal), and cognitive symptoms (such as disorganized thinking and impaired executive function).
Correct Answer is A
Explanation
A. Cocaine use typically results in stimulation of the central nervous system, leading to increased heart rate, dilated pupils, and heightened alertness.
B. Cocaine use is associated with tachycardia (increased heart rate) rather than bradycardia, and it usually increases respiratory rate rather than causing bradypnea.
C. Hallucinations and delusions are not typical effects of cocaine use; instead, they may occur with substances like hallucinogens or certain psychotic disorders.
D. Lethargy and depression are more commonly associated with the "crash" or comedown phase after cocaine use, rather than immediate effects of ingestion.
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