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. Discussing alternative strategies is important but might not be the initial priority without first assessing the client's physical health.
B. Providing a supportive environment for meals is crucial, but assessing the client's physical status should take precedence.
C. Monitoring for vomiting after meals is important, but a comprehensive assessment of physical health should come first.
D. Assessing weight, vital signs, and electrolytes is crucial in determining the client's current physical health status and any potential risks associated with bulimia.

A. Disturbed sensory perception. B. Compromised family coping. C. Impaired environmental interpretation. D. Ineffective sexual patterns.

Correct Answer is A

Explanation

A. The client's belief in having an extraordinarily high IQ and grandiose delusions about being married to a movie star are indicative of disturbed sensory perception.
B. While family coping might be impacted, the primary concern here is the client's altered perception of reality.
C. Impaired environmental interpretation might be related to the delusions but is not the primary problem.
D. Ineffective sexual patterns are not the primary concern in this scenario; the client's altered reality and delusions take precedence.

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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

A female client with bulimia is admitted to the mental health unit after she disclosed to a friend that she purges after meals. Which intervention should the nurse implement first?

Correct Answer is D

Explanation

A male client tells the nurse that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. Which is the priority nursing problem for admission to the psychiatric unit?

Correct Answer is A

Explanation

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