A nurse learns at report that a newly admitted client experiencing mania is demonstrating grandiose delusions. The nurse should recognize which client statement would provide supportive evidence of this symptom?
I'm the world's most perceptive attorney.
The FBI is out to get me
I can't stop my sexual urges. They have led me to numerous affairs.
My wife is distraught about my overspending
The Correct Answer is A
A. "I'm the world's most perceptive attorney.": This statement reflects grandiosity, a common feature of grandiose delusions. The client is expressing an exaggerated belief in their own importance and abilities, indicating a distorted perception of reality.
B. "The FBI is out to get me": This statement suggests paranoid delusions, where the client believes they are being persecuted or conspired against. It does not specifically indicate grandiose delusions.
C. "I can't stop my sexual urges. They have led me to numerous affairs": This statement reflects impulsivity and hypersexuality, which are common features in manic episodes but do not specifically indicate grandiose delusions.
D. "My wife is distraught about my overspending": This statement reflects a consequence of manic behavior (overspending) but does not directly indicate grandiose delusions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Altered thought process related to hallucinations: While altered thought processes are common in manic episodes, hallucinations are not typically associated with mania in Bipolar I disorder. Hallucinations are more commonly seen in psychotic disorders.
B. Risk for violence related to poor impulse control and judgment: This is the correct priority diagnosis. During a manic episode, individuals may have impaired impulse control and poor judgment, increasing the risk of impulsive and potentially violent behaviors. Ensuring the safety of the client and others is the priority.
C. Altered thought process related to poor judgment: While altered thought processes and poor judgment are characteristic of mania, the specific concern in this scenario is the potential for violence. The risk for violence takes precedence as a priority nursing diagnosis.
D. Social isolation related to mania: Social isolation may be a concern, but the immediate priority is addressing the risk for violence, as it poses a more significant threat to the client and others during a manic episode.
Correct Answer is A
Explanation
Orientation: When a nurse asks a client to identify their name, date, residential address, and situation, they are assessing the client's orientation. Orientation refers to an individual's awareness of time, place, person, and situation.
B. Affect: Affect refers to the observable expression of emotions. It involves the client's emotional tone, such as being happy, sad, angry, or flat. It is not directly assessed by asking about personal information.
C. Perception: Perception involves the way individuals interpret and make sense of sensory information. Asking about personal information is more related to orientation than perception.
D. Mood: Mood refers to a more sustained emotional state. It is not directly assessed by asking for specific personal information about the current situation or location.
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