Nokea
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.
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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.
A client who has a major depressive episode tells the nurse that for the past 2 weeks, he has been hearing voices and at times thinks that someone is following him. History reveals that he had these alternating symptoms before along with times when he has experienced neither of these symptoms and has been able to function adequately. The nurse interprets these findings as suggesting which of the following?
- A. Paranoid schizophrenia
- B. Undifferentiated schizophrenia
- C. Brief psychotic disorder
- D. Schizoaffective disorder
Correct Answer: D
Rationale: Schizoaffective disorder (D) combines mood episodes (depression) with psychotic symptoms (hallucinations, paranoia) that persist but allow periods of adequate functioning, matching the client?s history. Paranoid (A) and undifferentiated schizophrenia (B) lack prominent mood components, and brief psychotic disorder (C) is shorter in duration.
A family member of a client diagnosed with schizoaffective disorder asks a nurse what causes the disorder. Which response by the nurse would be most appropriate?
- A. Dysfunctional family dynamics has been identified as a strong link.
- B. Research has suggested that the cause is predominately genetic.
- C. Dopamine, a substance in the brain, appears to be underactive.
- D. Studies have indicated that birth order is strongly associated with this disorder.
Correct Answer: B
Rationale: Research indicates a strong genetic component (B) in schizoaffective disorder, with heritability estimates similar to schizophrenia. Family dynamics (A) are not a primary cause, dopamine is overactive (C) in psychosis, and birth order (D) lacks evidence as a cause.
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.
The nurse is caring for a client who was diagnosed with schizoaffective disorder. Based on the nurse?s understanding of this disorder, the nurse develops a plan of care to address which issue as the top priority?
- A. Suicide
- B. Aggression
- C. Substance abuse
- D. Eating disorder
Correct Answer: A
Rationale: Suicide (A) is the top priority in schizoaffective disorder due to the combined risk of mood disturbances (e.g., depression) and psychosis, both of which elevate suicide risk. Aggression (B), substance abuse (C), and eating disorders (D) are concerns but less immediate unless actively present.