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 B

Explanation

A. Urinary output might be important in some contexts but is not the priority related to the use of MAO inhibitors.
B. MAO inhibitors like phenelzine can affect blood pressure significantly; monitoring BP is crucial due to the risk of hypertensive crisis when certain foods or medications are taken.
C. Respiratory rate might be a consideration in some situations but is not directly affected by MAO inhibitors.
D. Temperature is not typically a primary concern related to MAO inhibitor use; blood pressure monitoring is more crucial due to potential interactions.

A. Consumption, liver enzyme, gastrointestinal complaints, and bleeding. B. Cancer screening results, anger, gastritis, daily alcohol intake. C. Minimizes drinking, frequently misses family events, guilt about drinking, amount of daily intake. D. Efforts to cut down, annoyance with questions, guilt, drinking as an "Eye-opener."

Correct Answer is D

Explanation

A. While liver enzymes and gastrointestinal complaints are important, they are not part of the CAGE questionnaire.
B. Cancer screening results, anger, and gastritis are not directly addressed by the CAGE questionnaire.
C. The listed items are relevant but not specifically addressed by the CAGE questionnaire.
D. Efforts to cut down, annoyance with questions, guilt, and drinking as an "eye-opener" are aspects explored in the CAGE questionnaire to assess alcohol dependency.

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

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Naxlex Comprehensive Predictor Exams

In conducting the initial assessment of a preoperative client, the nurse notes that the client's home medications include the monoamine oxidase (MAO) inhibitor phenelzine. Because of this client's medication history, which assessment finding is most important for the nurse to monitor?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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