The nurse is performing a mental health assessment for a client with schizophrenia. Which statement made by the client demonstrates that the client is having auditory hallucinations?
"Those voices keep telling me that I need to get a knife and cut myself."
"Can you hear those children singing in the room with us?"
"I keep smelling feces in the room, and I can't get the odor out of my nose."
"I keep tasting things that are foul like onions and garlic, but I don't eat those."
The Correct Answer is A
Choice A reason: This statement clearly indicates the presence of auditory hallucinations, which are a common symptom of schizophrenia.
Choice B reason: While this could suggest auditory hallucinations, it could also be a question about shared experience and not necessarily indicative of a hallucination.
Choice C reason: Smelling feces where there is none could indicate an olfactory hallucination, which is less common than auditory hallucinations in schizophrenia.
Choice D reason: Tasting foul substances that are not present could suggest gustatory hallucinations, which, like olfactory hallucinations, are less common in schizophrenia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Engaging in activities might be too demanding during a panic atack and could potentially exacerbate the client's anxiety.
Choice B reason: While medication may be part of the treatment plan, the immediate priority is to ensure the client's safety and comfort, which is best achieved by staying with them.
Choice C reason: Offering therapy in the midst of a panic atack is not practical; the immediate need is to help the client feel safe and manage their acute symptoms.
Choice D reason: Staying with the client to assess their needs is the most appropriate immediate intervention to ensure safety and provide reassurance during a panic atack.
Correct Answer is D
Explanation
Choice A reason: Teaching relaxation techniques after medication may not be as effective because the client might be under the influence of the medication, which could interfere with learning the techniques.
Choice B reason: Atempting to teach relaxation techniques during a ritual can increase the client's anxiety and resistance, as rituals are often used by individuals with OCD to manage their anxiety.
Choice C reason: While bedtime could be a calm time, it's not specifically targeted towards managing anxiety levels, which is crucial for clients with OCD.
Choice D reason: Teaching relaxation techniques when the client is experiencing low anxiety levels is most beneficial. The client is more likely to be receptive and retain the information, which can then be applied during higher anxiety periods.
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