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The nurse is talking to a group of student nurses about content of thought in clients with schizophrenia. The nurse gives an example of a client stating that her new tooth filling allows her to communicate with the Secret Service and follow their directives. Which response correctly identifies this content of thought?
- A. somatic delusion
- B. delusion of grandeur
- C. delusion of persecution
- D. delusion of control or influence
Correct Answer: D
Rationale: A delusion of control or influence involves believing external forces or entities control one's thoughts or actions, as in the client's belief that a tooth filling enables communication with the Secret Service.
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The nurse is caring for a client whose family brought him to the hospital because they were worried about his personal safety. Which of the following statements by the client during the admission assessment indicates the need for immediate intervention by the nurse?
- A. Things are so bad that sometimes I don't know what to do make them better.
- B. My family normally supports my goals and helps me when I have a difficult time.
- C. I wish that everyone would leave me alone and quit trying to give me advice all the time.
- D. I keep a gun in my nightstand and sometimes I fall asleep holding it, trying to decide if I should pull the trigger or not.
Correct Answer: D
Rationale: This statement indicates active suicidal ideation with a plan and means, requiring immediate intervention to ensure safety.
The mental health nurse is caring for a client with Cluster B personality disorder. The nurse would expect the client to exhibit which behaviors? Select all that apply.
- A. suspicious of others, magical thinking, eccentric behavior, paranoia, relationship deficits
- B. preoccupation with rules and details, hoarding, ritualistic behavior, extremely devoted to work
- C. easily bored, poor and shallow interpersonal relationships, enjoys being the center of attention
- D. impulsivity, unpredictable behavior, extreme mood shifts, easily angered, playing people against each other
- E. suspicious and untrusting of others, argumentative, controlling of others, thoughts of grandiosity
Correct Answer: C,D
Rationale: Cluster B personality disorders (e.g., histrionic, borderline) involve attention-seeking, shallow relationships, impulsivity, and mood instability. Options A and E describe Cluster A, and B describes Cluster C.
The nurse is educating a group of student nurses about perceived loss. The nurse knows that the students understand when one of them verbalizes which example?
- A. a single mother loses her job
- B. a student fails his college chemistry class
- C. a husband is grieving the loss of his wife of 40 years
- D. a first-time mother is disappointed that she had a boy instead of a girl
Correct Answer: D
Rationale: Perceived loss involves subjective disappointment, such as a mother's expectation of a different gender, unlike tangible losses like a job or spouse.
The nurse is assessing a client to determine the client's adjustment to presbycusis. Which indicates successful adaptation by the client to this problem?
- A. Proper use of a hearing aid
- B. Denial of a hearing impairment
- C. Withdrawal from social activities
- D. Reluctance to answer the telephone
Correct Answer: A
Rationale: Presbycusis occurs as part of the aging process; it is a progressive sensorineural hearing loss. Clients show adequate adaptation by obtaining and regularly using a hearing aid. Some clients may not adapt well to the impairment, denying its presence. Others withdraw from social interactions and contact with others, embarrassed by the problem and the need to wear a hearing aid.
The nurse has assessed the assigned group of clients. Which client would the nurse identify as being at the greatest risk for alterations in sensory perception?
- A. a client in a halo vest following an automobile accident
- B. a child with severe autism who is having a tonsillectomy
- C. a teenager who broke her leg during cheerleader practice
- D. a schoolteacher who was hospitalized for shortness of breath
Correct Answer: B
Rationale: Severe autism often involves sensory processing issues, increasing risk for altered sensory perception, especially during stressful events like surgery. Other clients (A, C, D) have no specific sensory risks indicated.