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. "Electrical current will flow through electrodes placed on your torso." Electrodes are placed on the scalp, either bilaterally or unilaterally, rather than on the torso. These electrodes deliver a controlled electrical stimulus to induce a therapeutic seizure, which can help alleviate severe depressive symptoms.
B. "It is not necessary to fast before the procedure." Fasting is required before ECT to prevent aspiration, as the client will receive general anesthesia and a muscle relaxant. Typically, clients must avoid food and liquids for at least 6 to 8 hours prior to the procedure.
C. "You will be awake during the procedure." The client is not awake during ECT, as they receive general anesthesia and a muscle relaxant. These medications ensure the client remains unconscious and immobile throughout the procedure to enhance safety and comfort.
D. "Your provider will likely schedule you for several treatments over a period of weeks." ECT is not a one-time procedure; it is typically administered two to three times per week for a total of 6 to 12 sessions. The number of treatments varies based on the client’s response, with improvements often occurring after multiple sessions.

A. Tell the client that there is nothing there. B. Ask the client to describe what is being seen. C. Touch the client's arm reassuringly. D. Remove the client from the room.

Correct Answer is B

Explanation

A. Tell the client that there is nothing there. Dismissing the client's perception may increase distress and reduce trust in the nurse-client relationship. A therapeutic approach acknowledges the client’s experience without reinforcing or denying hallucinations.
B. Ask the client to describe what is being seen. Encouraging the client to describe the hallucination helps assess its nature and severity. Understanding the content allows the nurse to provide appropriate support, ensure safety, and guide interventions.
C. Touch the client's arm reassuringly. Touching the client without consent, especially during a distressing hallucination, may escalate fear or agitation. Maintaining a calm and non-threatening presence is more appropriate.
D. Remove the client from the room. Relocating the client without assessing the hallucination may not address the underlying distress. Identifying triggers and using therapeutic communication are more effective initial interventions.

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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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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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