A nurse is caring for a client who has depression and states, "A government agency is attempting to capture me." The nurse should identify that the client is experiencing which of the following?

Inappropriate guilt

Mania

Delusions

Confusion

Answer and Explanation

The Correct Answer is C

A. Inappropriate guilt is a common symptom of depression, but it does not involve false beliefs about being targeted. Clients with major depressive disorder may feel excessive guilt, but this differs from the fixed, false beliefs seen in delusions.
B. Mania is characterized by elevated mood, impulsivity, and hyperactivity rather than paranoid thoughts. While manic episodes may include grandiose delusions, the belief that a government agency is attempting to capture the client aligns more with persecutory delusions.
C. Delusions are fixed, false beliefs that persist despite evidence to the contrary. The client’s statement suggests a persecutory delusion, which is commonly seen in psychotic disorders, including severe depression with psychotic features.
D. Confusion involves disorganized thinking, memory impairment, or difficulty understanding surroundings, often seen in delirium or cognitive disorders. While delusions can contribute to disorganized thoughts, they are distinct from general confusion.

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Correct Answer is D

Explanation

A. "Notify child protective services." Reporting to child protective services is only necessary if there is evidence of abuse, neglect, or an inability to provide adequate care. A diagnosis of borderline personality disorder alone does not warrant an automatic report.
B. "Suggest the children live with other relatives." Encouraging a client to relinquish custody without evidence of an inability to care for the children is not appropriate. Providing support and resources to enhance parenting skills is a more beneficial approach.
C. "Encourage the children to visit the psychiatric unit when the client is leaving." While family involvement is important, exposing young children to a psychiatric unit can be overwhelming and inappropriate. Alternative ways to support parent-child bonding should be considered.
D. "Offer the client information about a support group for parents." Support groups provide a structured environment for clients to share experiences, receive guidance, and develop coping strategies, which can help manage stress and improve parenting skills.

A. Provide reassurance and comfort ensuring the client is safe. B. Ensure the client goes to group activities as planned. C. Give PRN medications to treat increased hallucinations. D. Use distraction such as the television or music

Correct Answer is A

Explanation

A. "Provide reassurance and comfort ensuring the client is safe." Clients with schizophrenia experiencing confusion and thought distortions require reassurance and safety measures first. Confusion can increase the risk of self-harm or agitation, making safety a priority. Comforting the client and providing a structured environment can help reduce anxiety. Ensuring a calm and safe setting supports symptom management and overall well-being.
B. "Ensure the client goes to group activities as planned." While group activities can promote socialization, a client experiencing confusion and thought distortions may struggle to participate. Forcing group engagement without addressing immediate needs can increase distress. Individualized interventions should be prioritized before encouraging group involvement. Ensuring safety and reducing anxiety are more immediate concerns.
C. "Give PRN medications to treat increased hallucinations." PRN medications may help manage symptoms but are not the first priority. Assessing and ensuring safety takes precedence before administering medications. The nurse should first provide reassurance and evaluate the severity of symptoms. Medication is important, but nonpharmacological interventions should be attempted first when possible. Ensuring safety remains the immediate concern in managing schizophrenia-related confusion.
D. "Use distraction such as the television or music." While distraction techniques can be beneficial, they do not directly address confusion or distorted thinking. The client may require more structured interventions to reorient them and provide reassurance. Music or television might help in stable periods but may not be effective in acute distress. Ensuring the client’s safety and reducing distress are higher priorities in immediate care.

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A nurse is caring for a client who has depression and states, "A government agency is attempting to capture me." The nurse should identify that the client is experiencing which of the following?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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A nurse is caring for a client who has depression and states, "A government agency is attempting to capture me." The nurse should identify that the client is experiencing which of the following?