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."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale for A: Erythema of localized lesions may indicate an inflammatory condition or infection, which could suggest that the hair loss is disease-related.
Rationale for B: Evidence of patches of lost haircan be due to cosmetic products or abuse hence not conclusive
Rationale for C: Episodic complaints of pruritus could indicate an allergic reaction or infestation, which suggests a possible disease-related cause for the hair loss.
Rationale for D: Ecchymotic blood accumulations suggest trauma to the scalp.
C. Episodic complaints of pruritus (itching) might suggest irritation but do not conclusively indicate the hair loss is not disease-related.
D. Ecchymotic blood accumulations indicate bruising but are not typically associated with hair pain or loss.
Correct Answer is D
Explanation
A. White blood cell count might be relevant for other conditions but is not specific to NMS.
B. 24-hour urinary output might help evaluate kidney function but is not specific to NMS.
C. Blood sugar level might be important but is not the primary indicator of NMS.
D. Vital signs, such as temperature, blood pressure, heart rate, and respiratory rate, are crucial in assessing for NMS as it typically presents with changes in these parameters.
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