The nurse performing a physical assessment of a client with Alzheimer's disease documents that the client is delusional. Which of the following is an example of this mental alteration?
A) A client rummages though drawers without any purpose.
B) A client accuses a nurse of taking her slippers, which are under the bed.
C) A client hears voices telling her to leave the building.
D) A client believes that the nursing home has taken all her money.
D
Feedback:
Delusions can cause confused ideas, such as believing that a bank has confiscated all of the client's money or that a spouse is going to kill the client. Clients may show anxiety by rummaging through drawers, wringing their hands, pacing, or displaying worried looks. As they misplace things or cannot recall their location, clients may believe that items have been stolen and this paranoia may lead to accusations. Hallucinations are false sensory perceptions that may be auditory (e.g., hearing voices) or visual (e.g., seeing a person). Hallucinations may also involve the senses of taste, touch, and smell. Sometimes, clients believe that people on television are in the room with them or that their own reflection is another person.
You might also like to view...
ANS: C Capillary refill should take fewer than 3 seconds
xa. 1 second b. 2 seconds c. 3 seconds d. 4 seconds
What bariatric surgical procedure is recommended for long-term weight loss?
A) Gastric banding B) Vertical-banded gastroplasty C) Roux-en-Y D) Biliopancreatic diversion
A patient is scheduled for diagnostic tests to determine the cause of a hearing and balance disorder. For which diagnostic tests should the nurse prepare this patient?
Select all that apply. 1. tonometry 2. computed tomography (CT) scan 3. electronystagmography (ENG) 4. auditory evoked potentials (AEP) 5. auditory brainstem response (ABR)
A person who learns best by humming, singing, or playing an instrument is known as what type of learner?
a. Linguistic leaner b. Spatial learner c. Musical learner d. Interpersonal learner