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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Psychosocial history:

This includes information about the client's social, cultural, family, educational, and occupational background. It provides insights into the client's life circumstances, stressors, support systems, and overall psychosocial context. This information is crucial for understanding the context in which mental health symptoms may be occurring.

B. Vaccine history:

Vaccine history is not typically a primary factor in diagnosing mental health disorders. It is more relevant to preventive care and physical health.

C. History of allergies:

Allergies are primarily related to physical health and may not play a direct role in the diagnosis of mental health disorders.

D. Surgical history:

Surgical history is relevant to physical health conditions and is not a primary consideration in the diagnosis of mental health disorders.

A. Using authoritative leadership to help clients learn to conform to societal norms B. Being firm, consistent, and empathetic, while addressing specific client behaviors C. Promoting client expression by implementing laissez-faire leadership D. Overlooking inappropriate behaviors to avoid promoting secondary gains

Correct Answer is B

Explanation

A. Using authoritative leadership to help clients learn to conform to societal norms: Authoritative leadership may be perceived as controlling and is unlikely to be effective with clients diagnosed with borderline personality disorder. It can lead to resistance and difficulties in building a therapeutic alliance.

B. Being firm, consistent, and empathetic, while addressing specific client behaviors: This approach is most appropriate. Clients with borderline personality disorder often benefit from clear and consistent boundaries, along with empathy from the nurse. Addressing specific behaviors helps establish a structured and safe therapeutic environment.

C. Promoting client expression by implementing laissez-faire leadership: Laissez-faire leadership, characterized by minimal interference or direction, is generally not suitable for clients with borderline personality disorder. They may struggle with emotional dysregulation and benefit from a more structured and supportive approach.

D. Overlooking inappropriate behaviors to avoid promoting secondary gains: Overlooking inappropriate behaviors may reinforce maladaptive patterns and hinder progress in therapy. It is essential to address and work through specific behaviors while maintaining empathy and consistency.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is completing an assessment of a client. Which of the following information should the nurse anticipate the provider will use in the diagnosis of a mental health disorder?

Correct Answer is A

Explanation

Which nursing approach should be used to maintain a therapeutic relationship with a client diagnosed with borderline personality disorder?

Correct Answer is B

Explanation

Which hallucination necessitates the nurse to implement safety measures? The patient says.

A nurse is discussing the use of mechanical restraints with a newly licensed nurse. Which of the following situations should the nurse include as an indication for placing a client in mechanical restraints?

A nurse on an inpatient psychiatric unit implements care by scheduling client activities, interacting with clients, and maintaining a safe therapeutic environment. These actions reflect which role of the nurse?

A nurse is discussing bias issues in mental health with a newly licensed nurse. Which of the following statements should the nurse include in the discussion?

Which nursing diagnosis should be prioritized when providing care to a client diagnosed with paranoid personality disorder?

Which hallucination necessitates the nurse to implement safety measures? The patient says.

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The patient admitted with antisocial disorder will display which symptom(s)?