During an assessment, the nurse determines a patient is demonstrating symptoms of a psychosis. What did the nurse assess in this patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply
1. The patient says, "The servants need to be disciplined."
2. The patient says, "The voice told me to cut myself."
3. The patient laughs when asked about the health of a family member hospitalized for cancer treatment.
4. The patient asks to close the room door so "that man can't get to me."
5. The patient says, "I have not been able to get any sleep for months."
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 patient'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 patient.
Rationale 5: The lack of sleep is not a symptom of psychosis.
Global Rationale: Grandiose delusions, auditory hallucinations, and delusions are symptoms of psychosis. During a psychotic episode, the patient's mood and affect may vary widely and be inappropriate, such as laughing at sad events. The lack of sleep is not a symptom of psychosis.
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