The nurse is observing a client who is sitting alone in the day room. The client appears intently focused on the empty chair next to him. Suddenly the client begins laughing hysterically and making frantic hand gestures at the chair. When the nurse approaches the client, he looks over at the chair, whispers something unintelligible, and shakes his head. Based on this observation the nurse would assess the client's behavior as:
Disorganized speech
A hallucination
An illusion
Anhedonia
The Correct Answer is B
A. Disorganized speech: Disorganized speech involves incoherent or illogical speech patterns, which is not the primary observation here.
B. A hallucination: The client is interacting with an unseen entity, which suggests a hallucination, a false sensory perception, particularly common in schizophrenia.
C. An illusion: An illusion involves a misinterpretation of a real external stimulus, which is not applicable in this situation as there is no stimulus present.
D. Anhedonia: Anhedonia refers to a loss of interest or pleasure in activities, which does not describe the behavior observed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Generalized anxiety disorder: Generalized anxiety disorder involves persistent and excessive worry, but it does not typically present with the specific symptoms of nightmares and flashbacks related to trauma.
B. Posttraumatic stress disorder: PTSD is characterized by symptoms such as nightmares, flashbacks, and difficulty sleeping, especially following exposure to traumatic events. This fits the soldier’s presentation.
C. Obsessive-compulsive disorder: OCD involves recurrent, intrusive thoughts (obsessions) and/or repetitive behaviors (compulsions). The symptoms described do not align with OCD but rather with trauma-related symptoms.
D. Social phobia: Social phobia involves intense fear of social situations, not the trauma-related symptoms described. It is less relevant to the soldier’s experience of nightmares and flashbacks.
Correct Answer is B
Explanation
A. "Her family will no longer be dysfunctional." Completing a treatment program does not guarantee that family dynamics will change or improve immediately. Family dysfunction is often deeply rooted and requires separate or concurrent therapy.
B. "She'll need ongoing support to remain abstinent." Recovery from alcoholism is an ongoing process, and continued support, whether through therapy, support groups, or counseling, is critical to maintaining abstinence and preventing relapse.
C. "She doesn't need to be concerned about abusing alcohol in the future." This statement is inaccurate because individuals recovering from alcoholism must remain vigilant to prevent relapse. Alcoholism is a chronic condition, and the risk of relapse remains.
D. "She can learn to consume alcohol without problems." This is incorrect, as individuals who have struggled with alcoholism typically need to abstain completely from alcohol to prevent relapse.
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