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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Limit time for the client to perform activities. This intervention is not appropriate for a client with Alzheimer's disease. Limiting time for activities may increase agitation and frustration in individuals with cognitive impairments. Instead, it's important to allow adequate time for tasks and provide support as needed.

B. Talk the client through tasks one step at a time. This intervention is appropriate for a client with Alzheimer's disease. Breaking tasks into manageable steps and providing clear, simple instructions can help the client better understand and complete activities. This approach reduces confusion and frustration and promotes independence to the extent possible.

C. Provide an activity schedule that changes from day to day. Consistency is key in caring for individuals with Alzheimer's disease. A changing activity schedule may lead to increased confusion and disorientation. It's important to establish a routine and maintain consistency in daily activities and schedules to provide a sense of security and familiarity for the client.

D. Rotate assignment of daily caregivers. Consistency in caregiver assignments is essential for individuals with Alzheimer's disease. Changing caregivers frequently can disrupt the client's sense of security and increase confusion and anxiety. Continuity of care helps build trust and rapport between the client and caregivers, which is beneficial for the client's overall well-being.

A. Command hallucination B. Gustatory hallucination C. Visual hallucination D. Tactile hallucination

Correct Answer is A

Explanation

A. Command hallucination: Command hallucinations involve auditory hallucinations that instruct the individual to perform specific actions, often harmful or dangerous, such as self-harm or harm to others. These hallucinations can pose an immediate risk to the client's safety and the safety of others, making them the priority for nursing intervention.

B. Gustatory hallucination: Gustatory hallucinations involve perceiving tastes that are not present. While disturbing, they typically do not pose an immediate threat to the client's safety compared to command hallucinations.

C. Visual hallucination: Visual hallucinations involve seeing objects, people, or scenes that are not actually present. While they can be distressing, they may not pose an immediate risk to safety unless they trigger a fear response or contribute to disorientation.

D. Tactile hallucination: Tactile hallucinations involve the perception of physical sensations, such as tingling, burning, or insects crawling on the skin, in the absence of any external stimuli. While they can be distressing, they are less likely to pose an immediate risk compared to command hallucinations, which can lead to dangerous behaviors.

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Naxlex Comprehensive Predictor Exams

A nurse on a long-term care unit is creating a plan of care for a client who has Alzheimer's disease. Which of the following interventions should the nurse include in the plan?

Correct Answer is B

Explanation

A nurse is caring for a client who has schizophrenia and is experiencing a variety of hallucinations. Which of the following hallucinations is the priority for the nurse to address?

Correct Answer is A

Explanation

A nurse is assessing a toddler who has suspected lead poisoning. Which of the following findings should the nurse expect the client to manifest with acute lead poisoning?

A nurse is providing discharge teaching to a client who has bipolar disorder and will be discharged with a prescription for lithium. The nurse should teach the client that which of the following factors puts her at risk for lithium toxicity?

A nurse is caring for a 6-week-old infant who has a pyloric stenosis. Which of the following clinical manifestations should the nurse expect?

A nurse is caring for a newly admitted client who has obsessive-compulsive disorder (OCD). Which of the following actions should the nurse take first?

A nurse is caring for a toddler who is 24 hr postoperative following a cleft palate repair. Which of the following actions should the nurse take?

A nurse is assessing a preschooler. Which of the following findings should indicate to the nurse a need for speech therapy? (Select all that apply.)

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

A nurse observes that a client who has depression is sitting alone in the room crying. As the nurse approaches, the client states, "I'm feeling really down and don't want to talk to anyone right now." Which of the following responses should the nurse make?