A nurse is assisting with an admission interview for a client who has schizophrenia. He tells the nurse that he is receiving special audible messages from the Central Intelligence Agency that no one else is able to hear. The nurse should identify that the client is having which of the following alterations in perception?
Depersonalization
Hallucination
Illusion
Derealization
The Correct Answer is B
A. Depersonalization is a feeling of detachment from oneself or feeling like one's thoughts, feelings, and actions are not their own. It does not involve perceptual disturbances such as hearing voices.
B. Hallucination is a sensory perception that occurs in the absence of external stimuli. Auditory hallucinations involve hearing voices or sounds that others do not hear, as described by the client in this scenario.
C. Illusion is a misinterpretation of a sensory stimulus that is actually present in the environment. It involves a distortion or misperception of sensory information, not the perception of something that is not there, as in the case of hallucinations.
D. Derealization is a feeling of unreality or detachment from one's surroundings. It involves a distortion in the perception of the external world rather than sensory experiences such as hearing voices.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Fatigue is a common symptom of anemia, which can result from a low hemoglobin level.
Decreased oxygen-carrying capacity leads to feelings of tiredness.
B. Thickened fingernails are not typically associated with low hemoglobin levels. This symptom is more commonly seen in conditions such as fungal infections or psoriasis.
C. The need to go to the bathroom frequently is not directly related to low hemoglobin levels. It may be indicative of other conditions such as urinary tract infections or diabetes.
D. Shaky hands are not typically associated with low hemoglobin levels. This symptom may be seen in conditions such as essential tremor or Parkinson's disease.
Correct Answer is C
Explanation
A. Incorrect. Allowing the baby to finish a bottle at the next feeding increases the risk of overfeeding and can lead to problems such as excessive weight gain and discomfort.
B. Incorrect. Placing the baby on their stomach after feedings increases the risk of choking and is not recommended. The correct position is to place the baby on their back to sleep.
C. Correct. Newborns typically need to be fed approximately every 2-3 hours, which amounts to about six to eight feedings per day. This statement indicates an understanding of the frequency of feeding required for a newborn.
D. Incorrect. Adding rice cereal to a newborn's bottle is not recommended, especially without medical advice, as it can increase the risk of choking and may not be developmentally appropriate.
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