The nurse is observing a client who is sitting alone in the day room. The client appears intently focused on the empty chair next to him. Suddenly the client begins laughing hysterically and making frantic hand gestures at the chair. When the nurse approaches the client, he looks over at the chair, whispers something unintelligible, and shakes his head. Based on this observation the nurse would assess the client's behavior as:
Disorganized speech
A hallucination
An illusion
Anhedonia
The Correct Answer is B
A. Disorganized speech: Disorganized speech involves incoherent or illogical speech patterns, which is not the primary observation here.
B. A hallucination: The client is interacting with an unseen entity, which suggests a hallucination, a false sensory perception, particularly common in schizophrenia.
C. An illusion: An illusion involves a misinterpretation of a real external stimulus, which is not applicable in this situation as there is no stimulus present.
D. Anhedonia: Anhedonia refers to a loss of interest or pleasure in activities, which does not describe the behavior observed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Drink adequate noncaffeinated and non-alcoholic beverages: Xerostomia (dry mouth) can be alleviated by staying hydrated with noncaffeinated and non-alcoholic beverages, which help to moisten the mouth and improve comfort.
B. Take nutrient-dense foods or to combine plant-based proteins: While nutrient-dense foods are important for overall health, they do not specifically address the issue of xerostomia. Plant-based proteins do not directly impact the symptoms of dry mouth.
C. Take protein-based liquid supplements: Protein-based liquid supplements are not specifically designed to address dry mouth and may not help in alleviating xerostomia.
D. Get dental care and practice dental hygiene daily: While dental care and hygiene are important for overall oral health, they do not specifically address xerostomia. Drinking fluids is more directly helpful for managing dry mouth.
Correct Answer is A
Explanation
A. "It will not produce sedation like benzodiazepines." Buspirone is a non-sedative anxiolytic, making it safer for long-term use compared to benzodiazepines, which can cause sedation and other CNS depressant effects. This is the best response as it directly addresses the patient's concern about safety.
B. "It produces anticonvulsant action to prevent convulsions." Buspirone does not have anticonvulsant properties, and this response does not address the patient’s question about safety compared to benzodiazepines.
C. "It produces muscle relaxant effects to decrease back pain." Buspirone does not have muscle relaxant effects, and this response does not directly answer the patient’s concern about the safety of the medication.
D. "It provides you with a sleep additive to decrease insomnia." Buspirone does not have significant sedative or hypnotic effects, making this response incorrect.
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