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 ["A","B"]
Explanation
A. blurred vision: Blurred vision is a common side effect of tricyclic antidepressants due to their anticholinergic effects, and it can be a sign of overdose.
B. urinary retention: Urinary retention is another anticholinergic side effect of tricyclic antidepressants and can indicate an overdose.
C. diarrhea: Diarrhea is not typically associated with tricyclic antidepressant overdose. Anticholinergic effects generally lead to constipation, not diarrhea.
D. headache: While a headache can occur in many situations, it is not a specific indicator of tricyclic antidepressant overdose.
E. pale, moist skin: Pale, moist skin is not a typical symptom of tricyclic antidepressant overdose. Overdose symptoms more commonly include dry skin due to anticholinergic effects.
Correct Answer is A
Explanation
A. Repetitive thoughts and recurring impulses: OCD is characterized by obsessions (repetitive, intrusive thoughts) and compulsions (recurring impulses or behaviours performed to reduce anxiety). This choice best describes the core features of OCD.
B. Physical signs and symptoms with no physiologic cause: This description does not accurately describe OCD. While OCD symptoms are distressing and impairing, they are not typically categorized as having no physiologic cause.
C. Apprehension: Apprehension or general anxiety can be associated with many mental health disorders, but it is not specific to OCD, which is more about the presence of obsessions and compulsions rather than generalized apprehension.
D. Inability to concentrate: While inability to concentrate can be a symptom in various mental health disorders, it is not specific to OCD. OCD is more specifically characterized by repetitive thoughts and actions.
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