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 D
Explanation
Choice A reason: Offering information is supportive, but this does not address the spouse’s emotional needs or encourage discussion about the client’s values.
Choice B reason: Calling a chaplain might be supportive later, but it avoids addressing the spouse’s statement directly and risks shifting responsibility away from the nurse.
Choice C reason: Reassurance without exploring the client’s and family’s values minimizes the spouse’s need for deeper reflection and personal decision-making.
Choice D reason: Encouraging the spouse to reflect on the client’s beliefs and values promotes autonomy and supports decision-making that honors the client’s wishes, making it the most therapeutic response.
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.
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