A nurse is working with a client who is diagnosed with schizophrenia. During the admission assessment, the client says, “I’m just here to do undercover work. I’m the head of the FBI, I’ve worked closely with every president since Reagan.” This statement is an example of what symptom of schizophrenia?

Circumstantiality

Echolalia

Grandiose Delusions

Depersonalization

Magical Thinking

Answer and Explanation

The Correct Answer is C

A: Circumstantiality involves excessive and unnecessary detail in conversation, eventually reaching the point. It is not related to the content of the client’s statement, which is more about delusional thinking.

B: Echolalia is the repetition of another person’s spoken words. It does not apply to the client’s statement, which is an original delusional claim.

C: Grandiose delusions are false beliefs of exceptional abilities, wealth, or fame. The client’s claim of being the head of the FBI and working with presidents is a clear example of a grandiose delusion, reflecting an inflated sense of self-importance and unrealistic achievements.

D: Depersonalization involves feelings of detachment from oneself, as if observing oneself from outside the body. This symptom does not fit the client’s statement, which is more about delusional beliefs.

E: Magical thinking involves believing that one’s thoughts or actions can influence events in a way that defies the laws of cause and effect. The client’s statement does not reflect magical thinking but rather grandiose delusions.

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Correct Answer is A

Explanation

A: This statement requires follow-up because pretending that hallucinations are real can reinforce the patient’s delusions and is not a therapeutic approach. It is important to acknowledge the patient’s experience without validating the hallucinations as real.

B: This statement is appropriate as it directly assesses the presence of hallucinations in a clear and straightforward manner.

C: This statement is also appropriate as it helps to understand how the patient is managing their symptoms and can guide further interventions.

D: Assessing for command hallucinations is crucial because these types of hallucinations can pose a risk to the patient or others if they involve harmful commands.

A. She rarely eats meals with the family; instead, she sneaks food up to her room. B. She is too tired to do chores around the house, which is unusual for her. C. I know she has been very anxious lately; her schoolwork has been challenging her. D. She will feel a lot better when she finds out if she was accepted to her first-choice college.

Correct Answer is A

Explanation

A: This statement suggests secretive eating behaviors, which are characteristic of bulimia. Individuals with bulimia often eat large amounts of food in secret and then engage in compensatory behaviors such as purging. The mother’s observation that her daughter sneaks food to her room aligns with this pattern.

B: While fatigue and a lack of energy can be associated with various conditions, including eating disorders, this statement is not specific enough to indicate bulimia. It could be related to many other factors such as stress, depression, or physical illness.

C: Anxiety and academic challenges are common among adolescents but do not specifically point to bulimia. While stress can contribute to eating disorders, this statement alone does not provide enough evidence to suggest bulimia.

D: This statement reflects a situational stressor related to college acceptance but does not indicate any eating disorder behaviors. It is more about the adolescent’s emotional state and future plans rather than current eating habits.

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Naxlex Comprehensive Predictor Exams

A new nurse is preparing to assess a patient who is experiencing auditory hallucinations. Which statement by the nurse requires follow-up?

Correct Answer is A

Explanation

A nurse is caring for an adolescent who fainted at school. When interviewing the family, which statement by the mother best aligns with the diagnosis of bulimia?

Correct Answer is A

Explanation

Which client situation requires the nurse to prioritize the implementation of limit setting?

A patient with borderline personality disorder has cut her wrists while on the unit. Which of the following is NOT an appropriate nursing intervention?

A nurse is assessing the patient’s dietary habits. Which statement by the patient most closely aligns with binge eating?

The nurse is reviewing documentation after restraints were used. What item from the documentation should be removed?

A nurse is preparing to interview a family whose oldest child has an impulse control disorder. Which question would best assess them for symptoms of oppositional defiant disorder?

A patient who is experiencing auditory hallucinations has become increasingly agitated throughout the day. The patient suddenly kicks over an empty trash can and shouts “I WILL KILL YOU ALL!” at the wall. In response, the nurse should (Select all that apply).

A patient with schizophrenia has been admitted to an inpatient facility. Since admission, the patient has been either refusing medication or cheeking their medications. What interventions should the nurse implement? Select all that apply.

The nurse is participating in an IEP (Individualized Education Plan) for an 8-year-old male child diagnosed with Attention Deficit Hyperactivity Disorder. The nurse identifies which statement by the parent indicates more education is needed?