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
None
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Caring for an older parent and her own children simultaneously can lead to significant caregiver role strain due to the increased responsibilities and demands on the client's time and energy.
B. Feeling anxious to leave for personal appointments may indicate stress but does not specifically address caregiver role strain.
C. Taking naps in her car during lunch hour may suggest fatigue or exhaustion but does not directly relate to caregiver role strain.
D. Working an average of 60 hours per week may contribute to overall stress and fatigue but does not specifically address the client's role as a caregiver for her parent and children.
Correct Answer is C
Explanation
A. While a history of heart disease is important to consider, it is not the most crucial information to obtain prior to administering sertraline.
B. Familial history of mental illness is relevant but may not directly impact the immediate administration of sertraline.
C. Obtaining a thorough medication history is essential to identify potential drug interactions, allergies, or contraindications that could affect the safety and efficacy of sertraline.
D. While current weight may influence the dosing of certain medications, it is not typically a primary consideration prior to administering sertraline.
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