A nurse is assessing a client who has schizophrenia. The client tells the nurse. "My heart exploded and my blood is draining out." The nurse should interpret this statement as which of the following manifestations?
Paranoia
A somatic delusion
Concrete thinking
A visual hallucination
The Correct Answer is B
A. Paranoia:
Paranoia involves unfounded beliefs that others are plotting against, persecuting, or harming the individual. It is not directly related to the client's statement about bodily sensations.
B. A somatic delusion:
This is the correct choice. A somatic delusion is a false belief related to the body. In this case, the client believes that their heart exploded and blood is draining out, which is a somatic delusion involving bodily functions and sensations.
C. Concrete thinking:
Concrete thinking refers to a literal and straightforward way of thinking without the ability to interpret abstract or metaphorical language. While the client's statement is literal, it is not an example of concrete thinking. Concrete thinking would involve an inability to understand figurative language, which is not the case here.
D. A visual hallucination:
Visual hallucinations involve seeing things that are not present. The client's statement does not describe a visual experience but rather a false belief about bodily sensations, indicating a somatic delusion.
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Related Questions
Correct Answer is C
Explanation
A. "I will do my best to avoid crying in front of my loved ones."
This statement suggests the client might be trying to hide their emotions, which can lead to further emotional distress. Suppressing emotions, like crying, is not a healthy coping mechanism and can exacerbate feelings of sadness and isolation.
B. “I will stay in bed on days when I feel exhausted."
Staying in bed excessively, especially during the day, is a behavior associated with depression and can worsen depressive symptoms. Encouraging the client to maintain a regular sleep schedule and engage in activities, even if they are small, is a more beneficial approach. Physical activity and exposure to natural light can positively impact mood.
C. “I’ll use the coping mechanisms that helped me in the past."
This is the correct choice. Reverting to previously effective coping mechanisms indicates an understanding of self-awareness and the ability to recognize what has worked positively in the past. Coping mechanisms such as relaxation techniques, hobbies, social support, or therapy can be valuable tools in managing depressive symptoms.
D. “I will avoid talking about events that upset me."
Avoiding discussions about upsetting events can prevent the client from addressing and processing their emotions, hindering the therapeutic process. Encouraging open communication and expressing feelings with a trusted individual, therapist, or support group can help the client work through emotional challenges.
Correct Answer is D
Explanation
A. Monitor the client's sodium levels:
This action is not directly related to the administration of olanzapine. Olanzapine does not typically affect sodium levels directly. Monitoring sodium levels is essential for some other medications or conditions, but it is not a specific consideration for olanzapine administration.
B. Evaluate the client's frequency of panic attacks:
Evaluating the frequency of panic attacks is not directly related to the administration of olanzapine. Olanzapine is an antipsychotic medication used to treat conditions like schizophrenia and bipolar disorder. It is not primarily indicated for the treatment of panic attacks. Monitoring panic attacks would be relevant if the client's primary concern was panic disorder, but it's not the priority in this scenario.
C. Inform the client that application site rash is common:
This information is not relevant to the administration of olanzapine in the form of an intramuscular injection. Application site rash is a concern for topical medications or transdermal patches, not for IM injections. Therefore, informing the client about application site rash is not necessary in this context.
D. Observe the client for 3 hours following the administration of medication:
This is the correct action. Olanzapine extended-release IM injection requires close observation for at least 3 hours after administration. This monitoring period is essential due to the potential risk of post-injection delirium/sedation syndrome, which can occur shortly after the injection. Monitoring allows for the early detection of any adverse reactions, ensuring the client's safety and well-being.
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