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."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Explaining the phenomenon of opioid tolerance and receptor response reduction with continued use helps the client understand why increased dosage might be needed.
B. Collecting information on opioid sources is important but doesn't directly address the issue of increased tolerance.
C. Detoxification might be an extreme measure and is not the first step in addressing increased opioid tolerance.
D. Discussing the dangers of opioid misuse is essential, but it doesn't address the specific issue of increased tolerance for pain relief.
Correct Answer is D
Explanation
A. "Client has been sexually assaulted" is a formal and concise description. However, it isn’t written as a client would say it which is a key requirement in documentation of the presenting complaint.
B. "Client reported that she had sexual relations against her will" might be accurate but doesn't convey the severity of the situation as clearly as the term "sexually assaulted."
C. "Client claims that she was forced to participate in sexual intercourse" might describe the situation but doesn't necessarily reflect the urgency or trauma of the incident.
D. "Client states, 'My date raped me tonight'" is documented in the client’s own words and is descriptive enough to be the presenting complaint.
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