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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["A","B","C","D"]

Explanation

Social withdrawal: This is a common symptom as individuals may avoid social interactions and isolate themselves due to ongoing distress.
Prepared by Brandel
B) Exaggerated startle response: Individuals may have an increased startle reflex following trauma, which can persist over time.
C) Intrusive thoughts: These are unwanted and distressing thoughts related to the trauma that can continue to affect the individual.
D) Avoidance of places associated with the assault: This behavior is a protective mechanism to prevent re-experiencing the traumatic event.
E) Overeating: Overeating is not a characteristic sequalae of rape trauma. F) Hallucinations: Hallucinations are not typically associated with long-term symptoms of rape trauma syndrome. Hallucinations can occur in severe cases, particularly if there are co-occurring mental health disorders such as PTSD.

A. Involve client in daily exercise program. B. Ask the client to describe her depression. C. Spend time sitting in silence with client. D. Observe for signs of possible psychosis.

Correct Answer is C

Explanation

A. Involving the client in a daily exercise program may be beneficial for depression but does not directly address the issue of delayed responses during questioning.
B. Asking the client to describe her depression may be helpful for assessment purposes but does not address the immediate need of dealing with delayed responses.
C. Spending time sitting in silence with the client allows the nurse to provide a supportive presence without pressure for immediate responses, which can be helpful for a client experiencing depression-related delays in communication.
D. Observing for signs of possible psychosis is important but may not be indicated solely based on delayed responses; other symptoms would need to be present to warrant this concern.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse wants to teach the client about the long-term phase symptoms of rape-trauma syndrome. What symptoms are consistent with long-term rape trauma? Select all that apply.

Correct Answer is ["A","B","C","D"]

Explanation

When the nurse addresses questions to an adult client who is depressed, the client's responses are delayed. Which intervention should the nurse include in the client's plan of care?

Correct Answer is C

Explanation

A preschool-aged girl tells the school nurse that her hair hurts. The nurse finds that the child's hair has been arranged to cover several small bald spots. Which finding indicates to the nurse that the hair loss is not disease related?

An adult female client is brought to the Emergency Center after fainting at work. The nurse completes an assessment of the client and identifies caregiver role strain as a nursing problem. Which information best supports this problem?

Which intervention(s) should the nurse include in the plan of care for an adolescent client who is depressed? Select all that apply.

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?

A client with depression does not want to communicate with friends, uses television watching as a means of escaping responsibilities, and describes the inability to handle personal circumstances. Which coping strategy should the nurse include in the plan of care?