During a therapy session, the client states that he is 14 trillion years old and created the world. The nurse documents this statement as an example of which type of thinking displayed by the client?

Delusional thinking

Hallucination

Ideas of reference

Word salad

Answer and Explanation

The Correct Answer is A

Choice A reason: Delusional thinking involves fixed, false beliefs that are not grounded in reality and are resistant to evidence or reasoning. Claiming to be 14 trillion years old and the creator of the world reflects grandiose delusions, which are common in psychotic disorders such as schizophrenia or bipolar disorder with psychotic features.

Choice B reason: Hallucinations are sensory perceptions without external stimuli, such as hearing voices or seeing things that are not present. The client’s statement does not involve sensory misperception but rather a belief, so hallucination is not applicable.

Choice C reason: Ideas of reference involve misinterpreting external events as having personal significance, such as believing a TV show is sending messages specifically to the individual. This is not reflected in the client’s statement, which is more about identity and power.

Choice D reason: Word salad refers to incoherent speech with random words and phrases that lack logical connection. The client’s statement, while false, is coherent and structured, so it does not meet the criteria for word salad.

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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.

A. The client’s insight. B. The client’s concentration. C. The client’s self-concept. D. The client's judgment.

Correct Answer is D

Explanation

Choice A reason: Insight refers to a client’s awareness and understanding of their own condition or behavior. This scenario does not reflect the client’s awareness of illness or personal behavior but rather a response to an external event, so insight is not the focus of assessment here.

Choice B reason: Concentration involves the ability to maintain attention and focus on a task or thought. The client’s response does not indicate any difficulty with attention span or distractibility, so this is not the relevant domain being assessed.

Choice C reason: Self-concept relates to how a person views themselves, including their identity, worth, and roles. The client’s response does not reflect any self-evaluation or identity-related content, making this choice unrelated to the nurse’s intent.

Choice D reason: Judgment is the ability to make appropriate decisions in response to real-life situations. The client’s decision to pull over when signaled by a police officer demonstrates appropriate judgment. The nurse is assessing whether the client can respond logically and safely to societal expectations and legal cues.

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During a therapy session, the client states that he is 14 trillion years old and created the world. The nurse documents this statement as an example of which type of thinking displayed by the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The term nonmaleficence means:

Correct Answer is C

Explanation

A client reported to the nurse that, on his way to the clinic, a policeman in a patrol car turned on his lights and pulled him over. When asked what he did next, the client stated, "I pulled over, of course." Which of the following was the nurse trying to assess?

Correct Answer is D

Explanation

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Items included in the history section of the assessment include all of the following, except:

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An example of disenfranchised grief is: