The nurse documents that a client with schizophrenia is delusional. Which statement by the client confirms this assessment?

"The snakes on the wall are going to eat me."

"The nurse at night is trying to poison me with pills."

"The voices are telling me to kill the next person I see."

"The fire is burning my skin away right now."

None

Answer and Explanation

The Correct Answer is B

A. "The snakes on the wall are going to eat me." describes a visual hallucination, not a delusion. Hallucinations involve false sensory perceptions, such as seeing things that are not present. While hallucinations are common in schizophrenia, this statement does not indicate a delusion.

B. "The nurse at night is trying to poison me with pills." confirms a delusion, specifically a paranoid delusion. Delusions are fixed, false beliefs that are not based in reality and cannot be changed by logic or reasoning. In this case, the client irrationally believes that the nurse is trying to harm them, which is a classic symptom of schizophrenia.

C. "The voices are telling me to kill the next person I see." describes an auditory hallucination, which involves hearing voices or sounds that are not real. While auditory hallucinations are a common symptom of schizophrenia, this statement does not indicate a delusion.

D. "The fire is burning my skin away right now." describes a tactile hallucination, where the client falsely perceives sensations (e.g., burning). This is another form of hallucination, not a delusion, as it involves sensory misperception rather than a false belief.

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Correct Answer is B

Explanation

Rationale:
A. While participation in therapy is important, the primary focus should be on equipping the client with effective coping strategies to manage her anxiety.
B. This outcome directly addresses the client's maladaptive coping mechanism (scratching her wrists) by aiming to replace it with healthier coping strategies.
C. Learning relaxation techniques is beneficial, but it may not address the underlying issue of maladaptive coping behaviors like wrist scratching.
D. Taking antianxiety medications as prescribed is important for managing symptoms, but it does not directly address the client's maladaptive coping behavior or teach alternative coping strategies.

A. Ineffective community coping. B. B Disturbed sensory perception. C. Self-care deficit. D. Acute confusion.

Correct Answer is D

Explanation

A. Ineffective community coping may be a concern for a homeless individual but is not the priority in this scenario where the client is disoriented and confused.
B. Disturbed sensory perception typically involves alterations in visual, auditory, tactile, or olfactory senses, which may not be the primary issue in this case.
C. While self-care deficit could be a concern for a homeless individual, it is not the priority when the client is disoriented, disorganized, and confused.
D. Acute confusion is the priority problem because the client is disoriented, disorganized, and confused, indicating a cognitive impairment that needs immediate attention. E. There is no specific rationale provided for this option.

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The nurse documents that a client with schizophrenia is delusional. Which statement by the client confirms this assessment?

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Naxlex Comprehensive Predictor Exams

The nurse develops a plan of care for a female client who scratches her wrists in attempts to deal with anxiety. Which client outcome is most important to include in the plan of care?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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