A nurse is caring for a young adult client who has acute schizophrenic disorder and tells the nurse, "Yesterday noon the sun moon went over the rover to see the lawnmower.”. Which of the following manifestations is the client exhibiting?

Delusional disorder.

Anhedonia.

Associative looseness.

Hallucination.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Delusional disorder is characterized by the presence of one or more delusions for a month or longer, which could be plausible but are not real. This is not the case here.

Choice B rationale:

Anhedonia refers to the inability to experience pleasure, a common symptom in many mental disorders, including depression. It does not apply to this situation.

Choice C rationale:

Associative looseness, or loose associations, is a thought disorder characterized by speech in which ideas shift from one subject to another that is unrelated or minimally related. The client’s statement is an example of this.

Choice D rationale:

Hallucinations are sensory experiences that occur in the absence of actual stimulation. The client’s statement is not a hallucination, but a disorganized thought process.

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Correct Answer is B

Explanation

Choice A rationale:

Monitoring the client closely to prevent self-mutilation is more associated with self-harm disorders rather than dependent personality disorder.

Choice B rationale:

Giving positive feedback when the client is assertive with staff or clients can encourage independence and confidence.

Choice C rationale:

Discouraging flamboyant or seductive behaviors is more related to histrionic personality disorder.

Choice D rationale:

Setting limits to prevent exploitation of other clients is more associated with antisocial personality disorder.

A. "I know you hear the voices, but I do not.”. B. "The voices are part of your illness.”. C. "How often do you hear the voices?". D. "What are the voices telling you?".

Correct Answer is D

Explanation

Choice A rationale:

While acknowledging the voices can be part of therapeutic communication, it’s not the first response a nurse should make.

Choice B rationale:

Telling the client that the voices are part of their illness can be helpful, but it’s not the first response a nurse should make.

Choice C rationale:

Asking about the frequency of the voices can be part of the assessment, but it’s not the first response a nurse should make.

Choice D rationale:

Asking what the voices are saying can help assess if the client is experiencing command hallucinations, which could pose a safety risk.

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A nurse is caring for a young adult client who has acute schizophrenic disorder and tells the nurse, "Yesterday noon the sun moon went over the rover to see the lawnmower.”. Which of the following manifestations is the client exhibiting?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has dependent personality disorder. Which of the following actions should the nurse plan to take?

Correct Answer is B

Explanation

A nurse is caring for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following responses should the nurse make first?

Correct Answer is D

Explanation

A nurse is caring for a client who has bipolar disorder and is taking lithium. The client reports blurred vision and ataxia. Which of the following actions should the nurse take?

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A nurse is teaching a client who has bipolar disorder and a prescription for lithium to recognize the manifestations of toxicity. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is preparing to teach a client about his prescription of lithium for the treatment of bipolar disorder. Which of the following statements should the nurse include in the teaching?