A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse document as positive symptoms of schizophrenia? (Select all that apply.).

Auditory hallucinations.

Flight of ideas.

Decreased motivation.

Impaired memory.

Answer and Explanation

Correct Answer : A,B

Choice A rationale:

Auditory hallucinations are considered a positive symptom of schizophrenia. Positive symptoms are characterized by the presence of abnormal experiences or behaviors that are not typically present in individuals without schizophrenia. Auditory hallucinations involve hearing voices or sounds that are not real.

Choice B rationale:

Flight of ideas is a positive symptom of schizophrenia. It is characterized by a rapid and disorganized flow of thoughts, often leading to incoherent speech. This symptom is part of the formal thought disorder commonly seen in individuals with schizophrenia.

Choice C rationale:

Decreased motivation is not a positive symptom; it is considered a negative symptom of schizophrenia. Negative symptoms are characterized by a reduction or loss of normal functions or behaviors that are typically present in healthy individuals. Decreased motivation reflects a lack of interest, energy, or drive to engage in activities.

Choice D rationale:

Impaired memory is not a positive symptom but is more associated with cognitive deficits, which can be a part of schizophrenia, but it falls under cognitive symptoms rather than positive symptoms.

Choice E rationale:

Delusions of grandeur are positive symptoms of schizophrenia. Delusions are false beliefs that are firmly held despite evidence to the contrary. Delusions of grandeur involve a person having an exaggerated sense of self-importance or abilities. This is a classic positive symptom seen in schizophrenia. .

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Correct Answer is D

Explanation

Choice A rationale:

Asking the client to describe what makes them feel stressed is important for understanding their situation, but it is not the immediate priority when there is concern about self-harm.

Choice B rationale:

Inquiring about the client's past coping mechanisms is relevant, but it should not be the first question when there is a potential risk of self-harm.

Choice C rationale:

Discussing what the client is experiencing is important, but it is not the primary concern when there is a risk of self-harm.

Choice D rationale:

Asking the client if they are thinking of harming themselves is the immediate priority in this situation. It helps assess the client's safety and the need for further intervention. Please let me know if you have more questions or need further explanations. .

A. Command hallucinations. B. Impaired memory. C. Inappropriate speech patterns. D. Rapid mood swings.

Correct Answer is A

Explanation

Choice A rationale:

Command hallucinations require immediate intervention by the nurse. Command hallucinations are auditory hallucinations in which the client hears voices instructing them to perform specific actions, often harmful or dangerous. These hallucinations can lead to the client engaging in harmful behaviors or self-harm. The nurse must address this symptom promptly to ensure the client's safety and well-being.

Choice B rationale:

Impaired memory is a common symptom in clients with delirium, but it does not require immediate intervention. While impaired memory can be distressing for the client, it is not an immediate safety concern. The nurse should address memory deficits as part of the overall care plan but prioritize more urgent issues like command hallucinations.

Choice C rationale:

Inappropriate speech patterns are also common in clients with delirium. While they may be concerning, they do not typically pose an immediate risk to the client's safety. The nurse should assess and address inappropriate speech patterns but prioritize the safety of the client, especially when command hallucinations are present.

Choice D rationale:

Rapid mood swings are a symptom of delirium but, like impaired memory and inappropriate speech patterns, do not require immediate intervention to the same extent as command hallucinations. The nurse should address mood swings as part of the overall care plan and ensure that the client's safety is not compromised due to their condition.

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A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse document as positive symptoms of schizophrenia? (Select all that apply.).

Nursing Test Bank

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