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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Asking why the client feels they will never get better might come across as dismissive or confrontational.
Choice B rationale:
This response acknowledges the client’s feelings and offers a supportive approach to managing the symptoms of somatic symptom disorder. This disorder is characterized by a significant focus on physical symptoms that cause major distress and/or problems functioning. The main treatment is psychotherapy, and medication might be given in some cases.
Choice C rationale:
Focusing only on the physical symptoms might not address the emotional distress that the client is experiencing.
Choice D rationale:
While it’s important to offer hope, this response might come across as dismissive of the client’s current feelings.
Correct Answer is A
Explanation
Choice A rationale:
Assigning a staff member to stay with the client at all times is the priority action when a client declines to make a safety contract. This is because the immediate safety of the client is the primary concern in such situations.
Choice B rationale:
Locking the doors to the unit and securing windows so they cannot be opened might be considered a safety measure, but it is not the priority. The focus should be on direct supervision to ensure safety.
Choice C rationale:
Removing any objects from the client’s environment that could be used for self-harm is important, but it is not the priority. The immediate safety of the client through constant supervision is the priority.
Choice D rationale:
Providing the client with plastic eating utensils for meals is a safety measure, but it is not the priority. The immediate safety of the client through constant supervision is the priority.
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