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 D
Explanation
A. Provide client with high-calorie finger foods throughout the day:
While providing high-calorie finger foods may increase caloric intake, it may not be the most effective strategy for a specific weight gain goal. It's essential to encourage a balanced and varied diet.
B. Teach the importance of a varied diet to meet nutritional needs:
This is a good general approach to promote overall nutritional health, but it may not be specific enough to address the immediate goal of gaining 2 pounds within a week.
C. Initiate total parenteral nutrition to meet dietary needs:
Total parenteral nutrition is an invasive and aggressive intervention typically reserved for cases where oral or enteral feeding is not possible or insufficient. It is not the first-line approach for someone who can consume food orally.
D. Accompany client to cafeteria to encourage adequate dietary consumption:
This is the most appropriate intervention. Accompanying the client to the cafeteria provides an opportunity for direct encouragement and support during meals. It helps ensure that the client is consuming an adequate amount of food, which is crucial for the goal of gaining 2 pounds within a week.
Correct Answer is A
Explanation
A. By using a screening tool such as the CAGE questionnaire: This is the correct answer. The CAGE questionnaire is a widely used tool for screening alcohol use disorders. It consists of four questions that assess whether the individual has concerns or issues related to their alcohol consumption. A positive result may indicate a need for further assessment and intervention.
B. By asking directly if the client has ever had a problem with alcohol: While direct questioning is important, using a structured screening tool provides a more standardized and objective approach. The CAGE questionnaire offers specific questions that help identify potential issues with alcohol use.
C. By holistically assessing the client using the CINA scale: The CINA scale (Checklist of Nonverbal Indicators of Affect) is primarily used to assess nonverbal behaviors related to affect. While it may be useful in certain contexts, it is not specifically designed for assessing alcohol use disorders.
D. By referring the client for physician evaluation: While physician evaluation may be necessary for a comprehensive assessment, using a screening tool such as the CAGE questionnaire is an appropriate initial step. The results of the screening tool can guide further assessment and appropriate referrals.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
