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. 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.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}
Explanation
"If the client decides not to report their friend to the police, it is still a good idea to collect the evidence." Understanding: This statement acknowledges the importance of preserving evidence even if the client chooses not to involve the police. Collecting evidence can be crucial for future legal proceedings or for the client's own decision-making process.
-"Even if the client will not call the police, the nurse should advise the police of what has happened." No understanding: This statement suggests that the nurse should bypass the client's autonomy and directly involve the police without the client's consent. It fails to recognize the importance of respecting the client's autonomy and confidentiality.
-"The client has to consent in order for me to document his injuries in the chart." Understanding: This statement demonstrates an understanding of the importance of obtaining the client's consent before documenting any information related to their care, including injuries, in their medical chart.
-"Consent is not required to collect evidence from a person who has been sexually assaulted." No understanding: This statement is incorrect. Consent is always required, even when collecting evidence from a person who has been sexually assaulted. Failing to obtain consent could violate the individual's rights and lead to legal and ethical repercussions.
-"The sexual assault exam should only be done by a Sexual Assault Nurse Examiner, the Emergency Room attending physician, or other expert." Understanding: This statement correctly
Prepared by Brandel
identifies that sexual assault exams should ideally be performed by trained professionals, such as Sexual Assault Nurse Examiners or emergency room physicians with expertise in forensic examinations. These professionals are better equipped to handle the sensitive nature of such exams and collect evidence effectively.
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