A nurse is conducting a group therapy meeting and is sharing a humorous story. When the group laughs at the story, a client diagnosed with schizophrenia jumps up and runs out while yelling, "You are all making fun of me." The nurse recognizes that which of the following behaviors is this client displaying?

Ideas of reference.

Erotomania.

Grandeur.

Flight of ideas.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Ideas of reference involve the belief that external events, objects, or people have a specific and unusual significance directly related to oneself. In this scenario, the client with schizophrenia believes that the group's laughter is directed at them, indicating an exaggerated sense of personal relevance in the situation.

Choice B rationale:

Erotomania is characterized by the delusional belief that someone, usually of higher social status, is in love with the individual. This choice is not applicable to the situation described, where the client's reaction is centered around perceived mockery rather than romantic interest.

Choice C rationale:

Grandeur involves inflated feelings of importance, power, knowledge, or identity. It does not align with the situation where the client perceives ridicule and responds defensively to the group's laughter.

Choice D rationale:

Flight of ideas is a thought disorder characterized by rapid and unconnected shifts in thoughts, often associated with mania. It is not relevant to the client's reaction to the group's laughter.

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Correct Answer is ["C","D"]

Explanation

The correct answer is choice c. Believes that others are deceiving him, and choice d.Continuously holds onto grudges

Choice A rationale:

Perceiving oneself as inferior to others is more characteristic of avoidant personality disorder, where individuals often avoid social situations due to feelings of inadequacy and fear of rejection.

Choice B rationale:

Desiring to be the center of attention is a trait often seen in histrionic personality disorder, where individuals crave attention and may use dramatic behavior to achieve it.

Choice C rationale:

Individuals with paranoid personality disorder tend to have a pervasive and unjustified mistrust of others. They often believe that others are deceiving, exploiting, or harming them, even in the absence of evidence to support these beliefs. This mistrust is a central characteristic of this disorder.

Choice D rationale:

Continuously holding onto grudges is another hallmark feature of paranoid personality disorder. These individuals are prone to bearing grudges and being unforgiving, as they are hypersensitive to perceived slights or insults.

Choice E rationale:

Exhibiting a grandiose sense of self-importance is more characteristic of narcissistic personality disorder, where individuals have an inflated sense of their own importance and often lack empathy for others.

A. "You should try to see your partner's point of view before your own.” B. "Relationship difficulties are stressful and require effort to resolve.” C. "We could develop a plan for how to talk about this with your partner.” D. "Tell me more about the concerns that you have regarding your marriage.”

Correct Answer is A

Explanation

Choice A rationale:

This statement requires intervention by the charge nurse. The nurse is making a judgmental suggestion to the client about how they should approach their marital issues. The nurse's role is to provide support, empathy, and open-ended questions that allow the client to explore their feelings and thoughts. Making a directive statement like this can be perceived as controlling and dismissive of the client's feelings.

Choice B rationale:

Relationship difficulties being stressful and requiring effort to resolve is an appropriate and empathetic response from the nurse. This acknowledges the client's struggles and offers validation without imposing a particular solution.

Choice C rationale:

Developing a plan for communication is a constructive approach that helps the client address their concerns. This response is within the nurse's scope of practice and promotes problem-solving and effective communication between partners.

Choice D rationale:

Encouraging the client to share more about their concerns regarding their marriage is a therapeutic response. It shows active listening and facilitates the client's exploration of their feelings, which is an essential aspect of the nursing role in a therapeutic relationship.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has paranoid personality disorder. Which of the following findings should the nurse expect? (Select all that apply.).

Correct Answer is ["C","D"]

Explanation

A nurse is assessing a client who is sharing information regarding concerns about their marriage. The client states "My spouse and I argue most times." Which of the following statements by the nurse requires intervention by the charge nurse?

Correct Answer is A

Explanation

While in group therapy, a nurse is caring for a client who has cancer and is scheduled for immediate chemotherapy. The client tells the nurse that she wants to try nontraditional treatments first. Which of the following responses should the nurse make?

A nurse is caring for a child who has autism spectrum disorder. Which of the following findings should the nurse expect? (Select all that apply.).

A nurse is performing an admission assessment on a client who has been diagnosed with schizophrenia. Which of the following findings should the nurse identify as a negative symptom?

A nurse in the ER is admitting a client who has experienced a weight loss of 11 kg (25 lb) in the past 3 months. The client weighs 40 kg (88 lb) and believes she is fat. Which of the following aspects of care should the nurse consider the first priority for this client?

A nurse is caring for a client who has been diagnosed with end-stage liver cancer. The nurse recognizes that which of the following responses is an indication the client is in the denial phase of the grief process?

A nurse observes a client's spouse sitting alone in the waiting room crying. When approached, the spouse says, "I am really concerned about my husband." Which of the following is an appropriate response by the nurse?

A school nurse is speaking to the mother of a 16-year-old male adolescent. The mother has concerns about her son. Which of the following statements by the mother should indicate to the nurse that the adolescent is at risk for suicide?

A nurse is taking care of a client who is cognitively impaired. The nurse recognizes that which of the following rooms will provide a therapeutic environment for this client?