Nokea
A client with schizophrenia reads the advice column in the newspaper daily. When asked why the client is so interested in the advice column, the client replies, 'This person is my guide and tells me what I must do every day.' The nurse would best describe this type of thinking as which of the following?
- A. Referential delusion
- B. Grandiose delusion
- C. Thought insertion
- D. Personalization
Correct Answer: A
Rationale: Believing the advice column has personal significance indicates a referential delusion, unlike grandiose delusions (exaggerated self-importance), thought insertion, or personalization.
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A client with schizophrenia is admitted to the inpatient unit. He does not speak when spoken to but has been observed talking to himself on occasion. What would be the priority objective at this time?
- A. The client will begin talking with other clients
- B. The client will express his feelings freely
- C. The client will increase his socialization with others
- D. The client will increase his reality orientation
Correct Answer: D
Rationale: Increasing reality orientation is the priority to ground the client before addressing socialization or emotional expression, given his current withdrawn state.
A college freshman is admitted to the hospital with a diagnosis of schizophrenia. Friends reported that she had been in her room for 2 days in a trance-like state, not eating nor speaking to anyone. Which of the following is the highest priority for this client?
- A. Assessing fluid intake and output
- B. Completing an assessment of mental status
- C. Obtaining more data about her college experiences
- D. Providing for adequate rest
Correct Answer: A
Rationale: Assessing fluid intake and output prioritizes physiologic homeostasis, critical for a client not eating, over mental status, rest, or background data.
A client with schizophrenia is seen sitting alone and talking out loud. Suddenly, the client stops and turns as if listening to someone. The nurse approaches and sits down beside the client. Which of the following is the best initial response by the nurse?
- A. I can see you want to be alone. I'll come back another time.
- B. What are you hearing and seeing?
- C. I don't hear or see anyone else, what are you hearing and seeing?
- D. I can tell you are hearing voices but they are not real.
Correct Answer: C
Rationale: Asking what the client is experiencing while presenting reality validates their perception and encourages discussion, unlike dismissing, assuming, or denying the experience.
When performing discharge planning for a client who has schizophrenia, the nurse anticipates barriers to adhering to the medication regimen. The nurse assesses which of the following as improving the likelihood that the client will follow the prescribed medication regimen?
- A. Short-term memory intact
- B. History of missing appointments
- C. Receives monthly disability checks
- D. Walking is primary mode of transportation
- E. States location of pharmacy nearest his residence
Correct Answer: A,C,E
Rationale: Intact short-term memory, financial resources, and knowing the pharmacy location enhance medication adherence, unlike appointment history or transportation barriers.
The client with schizophrenia makes the following statement. 'I just don't know how to count. The sky turned to fire. I have a ball in my head.' The nurse documents this entire statement as an example of
- A. Flight of ideas
- B. Ideas of reference
- C. Delusional thinking
- D. Associative looseness
Correct Answer: D
Rationale: The fragmented, poorly related thoughts demonstrate associative looseness, not flight of ideas (rapid but connected thoughts), ideas of reference, or solely delusional thinking.