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 C
Explanation
A. Shifting attention from self to others might strain the individual further as they might not have the emotional energy for it.
B. Relaxation without addressing underlying issues won't help in managing depression and might exacerbate the situation.
C. Focusing on small achievable tasks helps in breaking down overwhelming problems into manageable parts, aiding in a sense of accomplishment.
D. Ventilating emotions might be beneficial, but solely relying on this strategy might not address the core issue of handling responsibilities.

Correct Answer is B
Explanation
A. Understanding the purpose of the medication regimen is important but might not be the most immediate concern.
B. Improving sleep to at least six hours a night addresses the client's reported insomnia and supports their physical well-being.
C. Describing the reasons for hospitalization might be essential for the client's understanding but might not have the immediate urgency.
D. Meeting the scheduled appointment with the dietitian is important for nutritional concerns but might not directly address the client's reported sleep and weight loss within the first three days of treatment.
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