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. 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.

A. Five-pound (2.3 kg) weight gain. B. Depressed affect. C. Nausea and vomiting D. Short-term memory loss.

Correct Answer is C

Explanation

A. A five-pound weight gain could be significant but might not require immediate reporting unless it continues to increase rapidly.
B. A depressed affect is concerning but may not warrant immediate reporting unless it signals a severe change in the client's mental state.
C. Nausea and vomiting could indicate lithium toxicity, a serious side effect requiring immediate attention and evaluation by the healthcare provider.
D. Short-term memory loss can be a side effect of lithium but might not pose an immediate threat unless severe or rapidly worsening.

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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

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