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 D
Explanation
Choice A rationale:
Stopping medication can be a sign of non-compliance or dissatisfaction with treatment, but it is not a direct warning sign of suicide.
Choice B rationale:
Requesting an appointment to discuss depression is a positive step towards seeking help and managing mental health.
Choice C rationale:
Sleeping 12 hours a day could indicate depression or other mental health issues, but it is not a specific warning sign of suicide.
Choice D rationale:
Giving away possessions can be a warning sign of suicide as it might indicate that the person is putting their affairs in order, which is a serious suicide warning sign.
Correct Answer is A
Explanation
Choice A rationale:
Muscle weakness is a manifestation of mild lithium toxicity. Lithium toxicity can occur at therapeutic levels, so clients should be monitored for adverse effects.
Choice B rationale:
Constipation is not typically associated with lithium toxicity. Diarrhea, not constipation, is a symptom of lithium toxicity.
Choice C rationale:
Urinary retention is not a typical symptom of lithium toxicity. Increased urination and thirst are common side effects of lithium.
Choice D rationale:
Hyperactivity is not a typical symptom of lithium toxicity. Lithium is used to manage bipolar disorder and can help reduce hyperactivity.
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