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

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

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

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

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

Answer and Explanation

The Correct Answer is C

A. "The snakes on the wall are going to eat me" indicates a hallucination, specifically a visual hallucination. Hallucinations involve perceiving something that is not present, such as seeing or hearing things that others do not. This statement does not confirm delusions.

B. Hearing voices instructing harm doesn't confirm delusions but auditory hallucinations.

C. "The nurse at night is trying to poison me with pills" reflects a delusion, specifically a persecutory delusion. Delusions are false, fixed beliefs that are not based in reality and are resistant to reasoning or contradictory evidence. This statement indicates a belief that someone is attempting harm, which is characteristic of delusional thinking.

D. Believing fire is burning the skin could suggest a hallucination involving sensations, not necessarily a delusion.

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Correct Answer is C

Explanation

A. Thoughts of wanting to hurt himself might be associated with various mental health conditions or medications but aren't specifically linked to olanzapine.
B. Diarrhea is a less common side effect of olanzapine and is not among the more frequently reported side effects.
C. Weight gain is a well-known side effect of olanzapine, with substantial increases reported in some cases.
D. Altered liver function tests are less commonly associated with olanzapine use compared to weight gain.

A. Involve client in a daily exercise program. B. Ask the client to describe her depression. C. Spend time sitting in silence with the client. D. Observe for signs of possible psychosis.

Correct Answer is C

Explanation

A. Initiating an exercise program might be helpful, but it doesn't directly address the delayed responses or aid in communication.
B. Asking the client to describe her depression might be beneficial, but it may not be suitable if the client's responses are delayed.
C. Spending time in silence with the client can create a safe and supportive environment, allowing the client to communicate at her own pace without feeling pressured.
D. Observing for signs of psychosis is important but doesn't directly address the delayed responses.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A male client tells the nurse that he does not want to take the atypical antipsychotic drug olanzapine because of the side effects he experienced when he took the drug for a year. Which experience is most likely related to taking olanzapine?

Correct Answer is C

Explanation

When the nurse addresses questions to an adult female client who is depressed, the client's responses are delayed. Which intervention should the nurse include in this client's plan of care?

Correct Answer is C

Explanation

A female client engages in repeated checks of door and window locks and behavior that prevents her from arriving on time and interfering with her ability to function effectively. Which action should the nurse take?

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