The nurse on the mental health unit receives report about a client diagnosed with schizophrenia who has a delusion of reference. Which client statement supports this symptom?
"I need for you to get rid of these bugs that are crawling under my skin."
"Those Martians are trying to poison me with the tap water."
"Hear that? She told me to kill my father."
"That song is a message sent to me in secret code."
The Correct Answer is D
Choice A reason: This describes tactile hallucinations, a false sensory experience, not a delusion of reference.
Choice B reason: This reflects a persecutory delusion, where the client believes they are being harmed or targeted, not a delusion of reference.
Choice C reason: This illustrates an auditory hallucination with command-type voices, not a delusion of reference.
Choice D reason: Believing that unrelated environmental cues (like a song) carry special, hidden meaning specifically for the client is the hallmark of a delusion of reference.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Sedative medications may be used in severe cases, but immediate nursing care focuses on nonpharmacologic interventions to ensure safety and reduce stimulation. Medication is not the first-line action.
Choice B reason: Providing a calm environment with reduced external stimuli while encouraging expression of feelings helps the client regain control and decreases anxiety during a panic episode. This is the most appropriate nursing intervention.
Choice C reason: Detailed problem-solving requires higher-level cognitive functioning, which is impaired during a panic attack. Attempting this intervention may increase the client’s distress.
Choice D reason: Allowing expression without guidance offers no therapeutic support and may leave the client overwhelmed by panic symptoms, prolonging the episode.
Correct Answer is D
Explanation
Choice A reason: Separation anxiety disorder involves excessive distress when separated from caregivers, but the key feature here is lack of speech in specific settings.
Choice B reason: Agoraphobia is the fear of being in situations where escape may be difficult, not selective inability to speak.
Choice C reason: Generalized anxiety disorder is characterized by excessive worry in many areas of life, not persistent mutism in social contexts.
Choice D reason: Selective mutism is an anxiety disorder where a child consistently fails to speak in certain settings, like school, despite being able to speak in others, making this the correct diagnosis.
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