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","C","E"]
Explanation
Choice A reason: Social withdrawal is a negative symptom of schizophrenia, reflecting reduced engagement rather than an excess or distortion of normal function.
Choice B reason: Delusional thinking is a hallmark positive symptom, representing a distortion of reality through fixed false beliefs.
Choice C reason: Bizarre or disorganized behavior, such as unusual movements or incoherent actions, is a positive symptom reflecting disruption in normal functioning.
Choice D reason: Flat affect is a negative symptom, reflecting diminished emotional expression rather than an added or distorted behavior.
Choice E reason: Auditory hallucinations are classic positive symptoms, involving perception of voices or sounds that are not present in reality.
Correct Answer is A
Explanation
Choice A reason: Consistent rules and firm boundaries are essential when working with individuals who display antisocial traits. Structure minimizes opportunities for manipulation and helps maintain safety and fairness on the unit.
Choice B reason: Offering sympathy and reassurance may reinforce manipulative behavior and undermine professional boundaries. It does not address the core issue of rule violation and lack of accountability.
Choice C reason: Allowing too much flexibility may increase opportunities for the client to exploit staff and disregard rules. This approach is counterproductive when dealing with manipulative behaviors.
Choice D reason: Developing a close, personal rapport risks blurring professional boundaries. Clients with these traits may exploit such relationships to gain privileges, which can disrupt treatment and unit structure.
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