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As part of an interdisciplinary team, a nurse is assisting in developing the plan of care for a client with a delusional disorder. Which of the following would the team be least likely to include in the plan?
- A. Insight-oriented therapy
- B. Psychoeducation
- C. Cognitive therapy
- D. Support therapy
Correct Answer: A
Rationale: Insight-oriented therapy (A) is least likely for delusional disorder, as clients often lack insight into their delusions, making this approach less effective. Psychoeducation (B), cognitive therapy (C), and support therapy (D) are more practical for managing symptoms and coping.
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When assessing a client with delusional disorder, the nurse would most likely expect to find impairment in which of the following? Select all that apply.
- A. Social functioning
- B. Marital functioning
- C. Intellectual functioning
- D. Occupational functioning
- E. Mental status functioning
Correct Answer: A,B,D
Rationale: Delusional disorder often impairs social (A), marital (B), and occupational functioning (D) due to the impact of delusions on relationships and work. Intellectual (C) and mental status functioning (E) typically remain intact, as the disorder is focal.
While caring for a hospitalized client with schizophrenia, the nurse observes that the client is listening to the radio. The client tells the nurse that the radio commentator is speaking directly to him. The nurse interprets this finding as which of the following?
- A. Autistic thinking
- B. Concrete thinking
- C. Referential thinking
- D. Illusional thinking
Correct Answer: C
Rationale: Referential thinking (C) describes the client?s belief that neutral events, like a radio broadcast, are personally directed at them, a common delusion in schizophrenia. Autistic thinking (A) involves private, illogical thoughts, concrete thinking (B) is overly literal interpretation, and illusional thinking (D) is not a standard term, making them incorrect.
The nurse is preparing to document information obtained from a client diagnosed with a delusional disorder who is experiencing somatic delusions. Which of the following would the nurse most likely document?
- A. Disorientation
- B. Reduced attention span
- C. Above average intelligence
- D. Body complaints
Correct Answer: D
Rationale: Somatic delusions in delusional disorder involve persistent beliefs about bodily functions or sensations (D), such as unusual odors or physical defects. Disorientation (A), reduced attention (B), and above-average intelligence (C) are not typically associated with somatic delusions.
When obtaining a client?s history, the nurse determines that the client has been experiencing delusions and hallucinations for the past 3 months, which has caused some problems in his ability to function on a daily basis at work. He also is exhibiting catatonic excitement, echopraxia, loose associations, and pressured speech. The nurse suspects which of the following?
- A. Schizophrenia
- B. Schizoaffective disorder
- C. Brief Psychotic disorder
- D. Schizophreniform disorder
Correct Answer: D
Rationale: Schizophreniform disorder (D) involves schizophrenia-like symptoms (delusions, hallucinations, disorganized speech, catatonia) lasting 1?6 months, matching the client?s 3-month duration. Schizophrenia (A) requires 6+ months, schizoaffective disorder (B) requires mood episodes, and brief psychotic disorder (C) lasts less than 1 month.
Assessment of a client with schizophrenia reveals that he is hearing voices that tell him that people are staring at him and illusions. When developing the plan of care for this client, which nursing diagnosis would be most appropriate?
- A. Disturbed thought processes
- B. Risk for self-directed violence
- C. Disturbed sensory perception
- D. Ineffective coping
Correct Answer: C
Rationale: Disturbed sensory perception (C) is most appropriate, as the client?s hallucinations (voices) and illusions directly indicate altered sensory processing. Disturbed thought processes (A) is less specific, risk for violence (B) is not indicated, and ineffective coping (D) is secondary.