While assessing a client with schizophrenia, the client states, 'Everywhere I turn, the government is watching me because I know too much. They are afraid that I might go public with the information about all those conspiracies.' The nurse interprets this statement as indicating which type of delusion?

Correct Answer: C

Rationale: The correct answer is C: Persecutory. This is because the client believes that the government is watching them and plotting against them, indicating a delusion of persecution. Grandiose delusions involve exaggerated beliefs of one's importance or abilities. Nihilistic delusions involve beliefs of non-existence or the end of the world. Somatic delusions involve beliefs about one's body being affected in some way. In this case, the client's belief aligns most closely with persecutory delusions, as they feel targeted and threatened by external forces.

Correct Answer: C

Rationale: The correct answer is C because stating that cognitive decline is normal in patients who are 65 and older is incorrect. Cognitive decline is not a normal part of aging and can indicate underlying health issues. It is important for the supervisor to correct this misconception to ensure proper care for older patients. Choices A, B, and D are all accurate statements commonly observed in older patients and do not require immediate correction.

Correct Answer: D

Rationale: The correct answer is D: splitting. Splitting is a common symptom of borderline personality disorder where individuals alternate between extremes of idealization and devaluation of others, such as partners. This behavior stems from the inability to integrate both positive and negative feelings towards the same person or object. It leads to black-and-white thinking and unstable relationships. A: Body illusion - This term does not relate to the alternating idealization and devaluation of partners seen in borderline personality disorder. B: Dissociation - Dissociation involves a disconnection from thoughts, feelings, or memories, and does not specifically address the idealization and devaluation pattern in relationships. C: Grandiosity - Grandiosity refers to an inflated sense of self-importance and superiority, which is not directly related to the pattern of idealization and devaluation in relationships seen in splitting.

Correct Answer: D

Rationale: The correct answer is D: "I never do anything right." This statement reflects a consistent negative self-perception and a lack of self-worth, which aligns with chronic low self-esteem. The patient attributes all their actions as failures, indicating a deep-rooted belief in their inadequacy. Choices A, B, and C focus on specific physical attributes or external factors, which do not directly relate to self-esteem issues. In contrast, choice D directly addresses the patient's perception of themselves and their abilities, supporting the nursing diagnosis of chronic low self-esteem.

Correct Answer: B

Rationale: The correct answer is B. Determining the level of anxiety in an older adult client is crucial for using an effective nursing intervention. By assessing anxiety levels, the nurse can tailor interventions such as relaxation techniques or therapeutic communication to address the client's needs. This personalized approach promotes better outcomes. Choice A is incorrect because determining anxiety levels should not solely be for administering medication without considering non-pharmacological interventions. Choice C is incorrect as anxiety assessment is not directly related to offering a specific diet. Choice D is incorrect because reporting to the prescriber is important but should not be the primary reason for assessing anxiety levels.