A nurse is conducting a group therapy session for several clients. The group is laughing at a joke one of the clients told, when a client who is schizophrenic jumps up and runs out of the room yelling. "You are all making fun of me!" The nurse should identify this behavior as which of the following characteristics of schizophrenia?
Looseness of association
ideas of reference
Magical thinking
Delusions of grandeur
The Correct Answer is B
A. Looseness of association: Looseness of association refers to a thought disorder characterized by disorganized thinking and lack of logical connections between thoughts. It typically presents as disjointed or fragmented speech patterns, rather than misinterpreting social cues or actions of others.
B. Ideas of reference: Ideas of reference are a characteristic feature of schizophrenia involving the belief that external events, objects, or actions have special significance specifically directed at oneself. In this scenario, the client's belief that others laughing at a joke is directed towards them is an example of ideas of reference.
C. Magical thinking: Magical thinking involves the belief that one's thoughts, actions, or words can influence external events or outcomes. It is often associated with superstitions and rituals. While magical thinking can occur in schizophrenia, it is not specifically demonstrated in this scenario.
D. Delusions of grandeur: Delusions of grandeur involve false beliefs of one's own importance, power, or identity. While delusions of grandeur are a symptom of schizophrenia, they are not evident in this scenario, as the client's reaction is more related to misinterpretation of social cues rather than an exaggerated sense of self-importance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Skin integrity: Skin integrity can be an indicator of dehydration, as dehydrated skin may appear dry and lack elasticity. However, skin turgor is not the most reliable indicator of fluid loss because it can be influenced by factors such as age and overall health. For example, infants and older adults may have decreased skin turgor due to a loss of skin elasticity, even if they are adequately hydrated.
B. Blood pressure: Blood pressure can decrease with significant fluid loss because there is less fluid volume to fill the arteries, leading to a drop in blood pressure. However, blood pressure is not the most reliable indicator of fluid loss because it can be influenced by many other factors, such as heart function and vascular resistance. Additionally, blood pressure may not change significantly until severe dehydration occurs.
C. Respiratory rate: An increased respiratory rate can be a sign of dehydration because the body may try to compensate for fluid loss by increasing the respiratory rate to deliver more oxygen to the tissues. However, an increased respiratory rate is a nonspecific symptom that can be associated with many other conditions, such as fever, pain, or lung disease. Therefore, it is not the most reliable indicator of fluid loss.
D. Body weight: Body weight is the most reliable indicator of fluid loss. This is because water makes up a significant portion of body weight, so a decrease in body weight is a direct indication of fluid loss. In infants, a rapid change in weight is often the first sign of fluid imbalance because they have a higher percentage of body water and a higher metabolic rate compared to adults. A 5% weight loss is considered mild dehydration, 10% is moderate, and 15% or more is severe. Therefore, regular monitoring of an infant’s weight is crucial when assessing for dehydration.
Correct Answer is C
Explanation
A. Bleeding: Haloperidol, an antipsychotic medication, is not typically associated with bleeding as an adverse effect. Bleeding is more commonly associated with medications such as anticoagulants or antiplatelet agents.
B. Pancreatitis: While rare, pancreatitis is not a common adverse effect of haloperidol. This condition is more commonly associated with other factors such as gallstones, alcohol consumption, or certain medications.
C. Dysrhythmias: Haloperidol can prolong the QT interval on an electrocardiogram (ECG), which may lead to dysrhythmias, including torsades de pointes. Therefore, it is essential to monitor clients receiving haloperidol for signs and symptoms of dysrhythmias, such as palpitations, syncope, or sudden cardiac arrest.
D. Cataracts: While long-term use of antipsychotic medications like haloperidol may increase the risk of developing cataracts, this adverse effect is not typically observed in clients receiving haloperidol on a PRN basis for agitation.
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