A 22-year-old man is brought to the office by his father. The client was diagnosed with schizophrenia 6 months ago and has been taking medication since. The father states that his son's dose isn't high enough and needs to be increased. He states that his son has been hearing things that don't exist. The nurse asks the young man what is going on. He says that his father is just jealous because his sister only talks to him. His father turns to him and says, "Son, you know your sister died 2 years ago!" His son replies "Well, she still talks to me in my head all the time!" Which best describes this client's abnormality of perception?

Hallucination

Perseveration

Fugue state

Illusion

Answer and Explanation

The Correct Answer is A

A.   A hallucination is a sensory experience that occurs without any external stimulus. It involves perceiving things that are not present in the environment, such as hearing voices or seeing things that are not there. The young man hearing his deceased sister talking to him in his head is an example of an auditory hallucination, which is a common symptom in schizophrenia.
B.   Perseveration is the repetitive and persistent repetition of a particular response, such as a word or action, despite the absence of a stimulus or the problem being resolved. It is not related to abnormal sensory perceptions but rather to repetitive behaviors or speech. The young man's experience of hearing voices does not fit this description.
C.   A fugue state is a type of dissociative disorder where a person suddenly and unexpectedly travels away from home or customary work locations and cannot recall their past. It often involves amnesia for personal history. The scenario described does not involve such travel or amnesia but rather auditory experiences, making this term irrelevant.
D.   An illusion is a misperception of an actual external stimulus. It involves incorrectly interpreting a real sensory input, such as mistaking a shadow for a person. Since the young man is not misinterpreting a real external stimulus but rather hearing something that is not present at all, an illusion does not accurately describe his experience.

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Correct Answer is B

Explanation

A. Extinction refers to the phenomenon where a person fails to recognize a stimulus on one side of the body when another stimulus is presented simultaneously on the opposite side. This is often tested in cases of neurological impairment, particularly in the context of sensory neglect or loss
B. Stereognosis is the ability to identify an object by touch and proprioception without visual input. It involves recognizing the shape, size, and texture of an object solely through tactile information. Placing a coin in the patient’s hand and asking them to identify it with their eyes closed tests their ability to use tactile information to recognize objects, making stereognosis the correct term for this assessment.
C. Proprioception is the sense of the position and movement of the body and its parts. It involves awareness of body position in space, which is crucial for coordination and balance. While important, proprioception does not specifically involve identifying objects by touch alone; it is more about the awareness of body position.
D. Two-point discrimination is the ability to distinguish between two closely spaced points of contact on the skin. It tests the sensitivity of the skin to touch and is often used to assess sensory nerve function. It does not involve identifying objects by touch but rather measuring how well one can discern between two separate points of contact.

A. Check for a Babinski reflex B. Position the client prone C. Ensure no injury to the cervical spine D. Check for evidence of fever and chills

Correct Answer is C

Explanation

A. The Babinski reflex is a test used to assess the integrity of the corticospinal tract and is particularly useful in evaluating neurological function in infants and adults with neurological conditions. However, it is not specifically related to testing for meningeal irritation.
B. Positioning the client prone (lying on their stomach) is not typically used when testing for meningeal irritation. The tests for meningeal irritation, such as the Brudzinski sign and Kernig sign, are performed with the client in a supine (lying on their back) position to accurately assess reactions to neck flexion and leg movements.
C. Before performing tests for meningeal irritation, such as neck flexion, it is important to ensure that the client does not have an injury to the cervical spine. If there is a possibility of cervical spine injury, performing neck flexion could exacerbate the injury. Ensuring that there is no cervical spine injury helps to avoid causing harm and ensures a safe examination.
D. While fever and chills can be associated with infections that may cause meningeal irritation (such as meningitis), checking for these symptoms is not the first step in assessing meningeal irritation itself.

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Naxlex Comprehensive Predictor Exams

The nurse places a coin in the patient's hand, the patient is with eyes closed. The ability to identify an object by feeling it is defined as:

Correct Answer is B

Explanation

When preparing to test a client for meningeal irritation, what would the nurse do first?

Correct Answer is C

Explanation

A 75-year-old male patient who recently started playing Tennis at the local adult care center is complaining of elbow pain associated with extension and flexion range of movement. The nurse knows the likely cause of this patient discomfort is due to:

A patient that is Comatose based on the Level of Consciousness (LOC) assessment using the Glasgow Coma scale is in what numeric range of the scale?

A client opens the eyes and answers questions however falls back asleep within seconds. How should the nurse document this assessment finding?

The client presents to the nurse stating that his jaws feel "stuck". What joint should the nurse assess?

A patient is diagnosed with Meningitis. During the physical examination in the supine position, the nurse flexed the patient's neck and the patient flexed his knees and hip while complaining of neck pain. This is known as:

A nurse is performing a physical examination on a patient. When the patient is asked to protrude his tongue, the nurse noticed a deviation from the midline to the right side. This is related to a lesion of:

While conducting an assessment the nurse suspects that a client is making up things in response to specific questions. What behavior is this client demonstrating?