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

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

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

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

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

Answer and Explanation

The Correct Answer is C

A. "The snakes on the wall are going to eat me" indicates a hallucination, specifically a visual hallucination. Hallucinations involve perceiving something that is not present, such as seeing or hearing things that others do not. This statement does not confirm delusions.

B. Hearing voices instructing harm doesn't confirm delusions but auditory hallucinations.

C. "The nurse at night is trying to poison me with pills" reflects a delusion, specifically a persecutory delusion. Delusions are false, fixed beliefs that are not based in reality and are resistant to reasoning or contradictory evidence. This statement indicates a belief that someone is attempting harm, which is characteristic of delusional thinking.

D. Believing fire is burning the skin could suggest a hallucination involving sensations, not necessarily a delusion.

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Correct Answer is D

Explanation

A. Increased talkativeness and pressure to keep talking might be seen in conditions like mania or anxiety, not specifically illness anxiety disorder.
B. Illogical responses could be indicative of thought disorders but are not characteristic of illness anxiety disorder.
C. Poor concentration and slow thought processes might suggest cognitive issues but are not specifically linked to illness anxiety disorder.
D. Ritualistic behaviors such as daily breast exams due to fear of cancer are characteristic of illness anxiety disorder (previously known as hypochondriasis).

A. Isolate the client from other clients. B. Administer a PRN sedative. C. Escort the client to a private area. D. Avoid recognizing the behavior.

Correct Answer is C

Explanation

A. Isolating the client might exacerbate feelings of social exclusion and isn't the best approach for managing echolalia.
B. Administering a sedative should not be the initial response to echolalia unless the behavior poses immediate harm to the client or others.
C. Escorting the client to a private area can help reduce the annoyance to other clients without isolating or punishing the individual.
D. Avoiding recognition of the behavior doesn't address the issue and might negatively impact the therapeutic relationship.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is conducting client assessments in an outpatient psychiatric clinic. Which client finding is characteristic of illness anxiety disorder?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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