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?
Derealization
Illusion
Hallucination
Depersonalization
The Correct Answer is C
c. Hallucination
In the scenario described, the client's experience of receiving special audible messages from the Central Intelligence Agency that no one else can hear indicates a hallucination. Hallucinations are perceptual disturbances in which a person experiences sensory perceptions without any external stimuli. They can occur in any sensory modality, such as hearing (auditory hallucinations), seeing (visual hallucinations), smelling (olfactory hallucinations), tasting (gustatory hallucinations), or feeling (tactile hallucinations).
In this case, the client is experiencing auditory hallucinations, as he is perceiving auditory stimuli (audible messages) that are not present in the external environment. Auditory hallucinations are most commonly associated with schizophrenia, although they can occur in other psychiatric disorders as well.
Derealization (option a) refers to a subjective feeling of unreality or detachment from the environment. It involves a perception that the external world is strange, distorted, or unreal. This is not the primary alteration in perception described in the scenario.
Illusion (option b) is a misinterpretation or misperception of a real sensory stimulus. It occurs when a person's perception of an actual stimulus is distorted or misunderstood. There is no indication of a misperception of a real stimulus in the scenario.
Depersonalization (option d) is a subjective experience of being detached from one's own body, thoughts, or emotions. It involves a feeling of being outside of oneself or observing oneself from a distance. This is not the primary alteration in perception described in the scenario.
Therefore, the correct answer is c. Hallucination, as the client's experience of receiving special audible messages that no one else can hear represents an auditory hallucination.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
d. Observe the client for 1 hr after meals.
Explanation:
The correct answer is d. Observe the client for 1 hr after meals.
For a client with bulimia nervosa, it is important to closely monitor their behavior after meals to prevent purging behaviors and ensure their safety. Observing the client for 1 hour after meals allows the nurse to provide support, encourage healthy coping strategies, and intervene if necessary to prevent purging episodes.
Option a, administering bupropion 1 hour before meals, is not an appropriate intervention for bulimia nervosa. Bupropion is an antidepressant medication that may be used for certain mood disorders, but it is not the primary treatment for bulimia nervosa.
Option b, allowing the client access to food throughout the day, is not a recommended intervention for a client with bulimia nervosa. Clients with bulimia nervosa often struggle with impulse control and binge eating behaviors. Allowing unrestricted access to food may exacerbate their symptoms and increase the risk of binge-purge cycles.
Option c, weighing the client once weekly, is not the most appropriate intervention for managing bulimia nervosa. While weight monitoring may be a component of treatment, it should not be the sole focus. The treatment for bulimia nervosa involves addressing the underlying psychological and behavioral factors contributing to the disorder.
By recommending the observation of the client for 1 hour after meals, the nurse can provide necessary support, monitor the client for potential purging behaviors, and promote a safe and therapeutic environment for their recovery from bulimia nervosa.

Correct Answer is D
Explanation
a. Oil-based lubricant
Explanation:
The correct answer is a. Oil-based lubricant.
When preparing to insert a nasogastric tube for gastric decompression, the nurse should obtain an oil- based lubricant. Lubricating the nasogastric tube before insertion helps facilitate smooth passage through the nasal passages and into the stomach, reducing discomfort and potential trauma to the client.
Option b, an enteric feeding pump, is not necessary for the insertion of a nasogastric tube for gastric decompression. An enteric feeding pump is used for administering enteral feedings, which is a different procedure and indication
Option c, sterile gloves, may be needed depending on the facility's policy and the specific circumstances of the client. While maintaining aseptic technique is important during the procedure, sterile gloves may not always be required for nasogastric tube insertion. Clean gloves or a clean hand hygiene practice may be sufficient in some cases.
Option d, pH strips, are not typically needed for nasogastric tube insertion for gastric decompression. pH strips are more commonly used to check the acidity or alkalinity of body fluids, such as gastric aspirate, to confirm placement of the nasogastric tube in the stomach.
By obtaining an oil-based lubricant, the nurse ensures the appropriate preparation for the nasogastric tube insertion, promoting the client's comfort and safety during the procedure.
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