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 B
Explanation
The nurse should include the statement that only health care staff providing care will see the client's medical record when reinforcing teaching about confidentiality. This statement emphasizes the importance of maintaining the privacy and confidentiality of the client's personal health information.
Explanation for the other options:
a. "Your nurse will provide information about the risks and benefits of surgical procedures." While it is important for the nurse to provide information about surgical procedures, this statement does not specifically address confidentiality.
c. "The provider must grant you access to your personal health information." This statement is related to the client's rights regarding access to their personal health information. While it is important to educate clients about their rights, it is not specifically focused on confidentiality.
d. "You have to authorize our providers to prescribe treatments for your condition." This statement is related to obtaining the client's consent for treatment, which is important but not directly addressing confidentiality.
Correct Answer is C
Explanation
The nurse should inform the family that the client has the right to refuse medication. It is important to
respect the client's autonomy and right to make decisions about their own care.
a) Scheduling the medication at meal times does not address the issue of the client refusing their medication.
b) Requesting that the family talk to the provider about administering the medication by injection may be an option, but it does not address the issue of informed consent.
d) Asking the family what foods the client likes does not address the issue of informed consent and could be seen as a way to deceive the client into taking their medication.
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