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?

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Question 1 of 5

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?

Correct Answer: D

Rationale: The correct answer is D: Body complaints. Somatic delusions involve false beliefs about one's body, such as having a serious illness or physical defect. The nurse would document the client's body complaints as they are directly related to the somatic delusions. Disorientation (A) and reduced attention span (B) are not specific to somatic delusions. Above average intelligence (C) is unrelated to the client's delusional disorder.

Question 2 of 5

The sleep history of a client experiencing sleep problems reveals that the client ingests a significant amount of caffeine each day. When reviewing the effect of caffeine on sleep with the client, which of the following would the nurse incorporate into the discussion as a caffeine effect?

Correct Answer: C

Rationale: The correct answer is C: Decreased REM sleep. Caffeine is a stimulant that can interfere with the sleep cycle by reducing the amount of REM (rapid eye movement) sleep, which is crucial for restorative functions. Here's the rationale: 1. Caffeine blocks adenosine receptors, which can disrupt the natural sleep stages, including REM sleep. 2. REM sleep is important for memory consolidation and cognitive function, so a decrease in REM sleep can lead to cognitive impairments. 3. Choices A and B are incorrect because caffeine typically increases sleep latency and decreases total sleep time. 4. Choice D is incorrect because caffeine is known to reduce slow-wave sleep, which is the deep, restorative stage of sleep.

Question 3 of 5

The nurse makes a home visit to a family caring for a client with Alzheimer's disease. The client's wife tells the nurse that she hasn't been out of the house for more than 2 weeks because her sister has been unable to help her care for the client. Which nursing diagnosis would the nurse identify as the priority?

Correct Answer: C

Rationale: The correct answer is C: Caregiver Role Strain related to social isolation. The priority nursing diagnosis addresses the wife's current state of distress due to social isolation, which can impact her ability to provide care for the client. This diagnosis directly addresses her feelings of being overwhelmed and unable to fulfill her caregiving role effectively. In contrast, option A focuses on family coping, which is secondary to the wife's immediate need for support. Option B is not as relevant since it does not address the wife's emotional and psychological stress. Option D refers to the client's emotional state rather than the wife's, making it less of a priority in this scenario.

Question 4 of 5

A nurse is working with a forensic client on de-escalation techniques. Which activity would be most appropriate as a grounding physical activity?

Correct Answer: C

Rationale: Grounding physical activities help individuals focus and stay present. Aerobic exercise, such as jogging or jumping jacks, can help regulate emotions and reduce stress by increasing endorphins. It also promotes mindfulness through rhythmic movements. Drumming (A), while rhythmic, may not provide the same level of physical activity. Rocking in a rocking chair (B) may not be stimulating enough for grounding. Yoga (D) focuses more on relaxation and mindfulness rather than the energizing effect needed for de-escalation.

Question 5 of 5

A nurse is assessing a client brought to the hospital psychiatric emergency services by a law enforcement officer. The client has disorganized, incoherent speech with loose associations and religious content. You should recognize the signs and symptoms as being consistent with which of the following?

Correct Answer: B

Rationale: The correct answer is B: Schizophrenia. The client's symptoms of disorganized, incoherent speech with loose associations and religious content are classic features of schizophrenia, specifically the positive symptoms. Schizophrenia is a severe mental disorder characterized by disturbances in thinking, emotions, and behavior. It typically presents in late adolescence or early adulthood. On the other hand, the other choices are incorrect because Alzheimer's disease primarily affects memory and cognitive function, substance intoxication would manifest with different symptoms depending on the substance, and depression typically presents with persistent feelings of sadness, hopelessness, and loss of interest in daily activities.

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