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 A
Explanation
A) Correct. Encouraging participation in physical activities can help channel excess energy and agitation associated with manic episodes.
B) Incorrect. Group card games may not provide an outlet for the high energy level typically seen in a manic episode.
C) Incorrect. While Bingo is a social activity, it may not be sufficient to address the high energy and potential restlessness seen in a manic episode.
D) Incorrect. Creating a new interactive game may not be feasible or appropriate in the acute setting, and it may not effectively address the client's current needs.
Correct Answer is D
Explanation
A. While medication review may be necessary, the immediate concern is the client's current symptoms and potential need for urgent intervention.
B. Encouraging the client to eat more slowly does not address the urgent nature of the client's symptoms.
C. "Assessment security" is not a standard term or intervention. It does not provide specific guidance for addressing the client's symptoms.
D. Given the client's complaints of swelling and tightness, along with difficulty swallowing, further assessment is needed to determine the cause. This information should be reported to the provider promptly.
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