During an assessment, the nurse determines a client is demonstrating symptoms of a psychosis. Which clinical manifestations did the nurse find during the assessment of this client?

Question

Standard Text: Select all that apply.
1. The client says, "The servants need to be disciplined."
2. The client says, "The voice told me to cut myself."
3. The client laughs when asked about the health of a family member hospitalized for cancer treatment.
4. The client asks to close the room door so "that man can't get to me."
5. The client says, "I have not been able to get any sleep for months."

Answer 1

Correct Answer: 1,2,3,4
Rationale 1: This statement is an example of a grandiose delusion.
Rationale 2: This statement is an example of an auditory hallucination.
Rationale 3: During a psychotic episode, the client's mood and affect may vary widely and be inappropriate, such as laughing at sad events.
Rationale 4: This statement is an example of a delusion in which someone is trying to harm the client.
Rationale 5: The lack of sleep is not a symptom of psychosis.
Global Rationale: The lack of sleep is not a symptom of psychosis. All other findings indicate symptoms of psychoses including grandiose delusion, auditory hallucination, and inappropriate responses.