A newly admitted client diagnosed with paranoid schizophrenia is super vigilant and constantly scans the environment. The client states, "I saw doctors talking in the hall. They were plotting to kill me." Which of the following does the nurse correctly identify as this behavior?
An idea of reference
A delusion of infidelity
An auditory hallucination
Echolalia
The Correct Answer is A
A) Correct. An idea of reference is a false belief that ordinary events, objects, or behaviors of others have a particular and unusual meaning directly pertaining to oneself. In this case, the client believes that the doctors' conversation in the hall is about them.
B) Incorrect. A delusion of infidelity involves a false belief that one's partner is being unfaithful.
C) Incorrect. Auditory hallucinations involve hearing things that are not present.
D) Incorrect. Echolalia is the repetition of another person's words.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
A) Incorrect. While it's important to avoid dehydration, this option is not specific to lithium use.
B) Correct. Lithium can cause dehydration, so it's crucial for the client to drink adequate fluids daily.
C) Correct. A low sodium diet is important while taking lithium, as high sodium levels can affect lithium absorption and potentially lead to toxicity.
D) Correct. Routine blood work is necessary to monitor lithium levels and ensure the client's levels remain within the therapeutic range.
E) Incorrect. Dependency is not a common concern with lithium.
Correct Answer is B
Explanation
A) Incorrect. While understanding the reasons behind the suicidal thoughts is important, in this immediate situation, assessing access to means (medications) is crucial.
B) Correct. This question assesses the immediate risk by determining if the friend has access to the means (medications) to carry out the overdose.
C) Incorrect. While substance use is a risk factor, it may not directly address the immediate threat of overdose with pills.
D) Incorrect. While family issues can contribute to emotional distress, the most pressing concern is the immediate risk of overdose.
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