A nurse observes a client talking to himself at the end of the hall. The client states, “No, I don't want to go." What does the nurse suspect regarding this information?
The client is expressing attention-seeking behavior.
The client has schizophrenia.
The client is having auditory hallucinations.
The client has multiple personalities.
The Correct Answer is C
Choice A reason: Attention-seeking behavior is typically deliberate and goal-oriented. In this case, the client is alone and speaking to unseen stimuli, which is more consistent with psychotic symptoms than manipulative behavior.
Choice B reason: While schizophrenia may be the underlying diagnosis, the nurse cannot confirm this based on one observation. The behavior described is a symptom, not a diagnosis.
Choice C reason: Auditory hallucinations involve hearing voices or sounds that are not present. The client’s statement suggests he is responding to internal stimuli, which is a hallmark of auditory hallucinations and common in psychotic disorders.
Choice D reason: Multiple personality disorder, now known as dissociative identity disorder, involves distinct identity states, not necessarily talking to oneself in response to hallucinations. This diagnosis is rare and cannot be inferred from the described behavior.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: A client’s past experiences with healthcare can shape their current attitudes, trust, and willingness to engage. Negative experiences may lead to resistance or anxiety, while positive ones may foster cooperation. This factor directly influences assessment quality.
Choice B reason: The client’s cognitive ability to understand questions and instructions is essential for accurate assessment. Misunderstanding can lead to incomplete or inaccurate data, affecting clinical decisions.
Choice C reason: Active participation and feedback from the client enhance the accuracy and depth of the assessment. It allows the nurse to clarify, explore, and validate information, making it a critical factor.
Choice D reason: While the client’s ability to work may be relevant in functional assessments or discharge planning, it does not directly influence the nurse’s ability to assess the client’s current health status, understanding, or needs. Therefore, it is not a primary factor in the assessment process.
Correct Answer is C
Explanation
Choice A reason: Treating people fairly and equally refers to the principle of justice. It emphasizes equitable distribution of resources and impartiality in care, not the avoidance of harm.
Choice B reason: The right to self-determination and independence is the principle of autonomy. It supports informed consent and respect for the client’s choices, but it is distinct from nonmaleficence.
Choice C reason: Nonmaleficence is a foundational ethical principle in healthcare that obligates providers to avoid causing harm. This includes both acts of commission and omission. Nurses must consider the risks of interventions and strive to minimize potential harm in all aspects of care.
Choice D reason: Honesty and truthfulness fall under the principle of veracity. While important, veracity is separate from the obligation to prevent harm.
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