Thought Disorders

Question 1

A client is sitting alone talking quietly. There is no one around. What nursing action should be taken?

Answer 1

Quietly approach the client and note the behavior. Assess the content of the hallucinations (e.g. “I noticed you talking. Are you hearing voices? Can you tell me about the voices you are hearing?”)

Question 2

A client dials 222-2222 and asks for his fiancé, naming a known movie star. This is an example of what type of thought disorder?

Answer 2

Delusion of grandeur
- Fixed, false belief that one possesses superior qualities such as genius, fame, omnipotence [quality of having unlimited or very great power], or wealth

Question 3

A client has been sitting in the same position for 2 hours. He is mute. What type of schizophrenia is this client experiencing? Describe appropriate nursing interventions for this client

Answer 3

Catatonic

• A state of neurogenic motor immobility and behavioral abnormality manifested by stupor (a state of near unconsciousness or insensibility; greatly diminished responsiveness to stimuli & usually impaired consciousness)
• Interventions: spend time with client; assist with ADLs; be alert to potential for violence toward self or others; be aware of fluid and nutrition needs

Question 4

A client is very agitated. He believes that the Central Intelligence Agency (CIA) has tapped the phone and is sending messages through the television and that you are an agent who has been planted by the agency. In order of priority, list the appropriate nursing actions when intervening in this situation. What type of delusion is this client experiencing?

Answer 4

• Approach client and offer solitary activity as distraction. Assess need for medication. Encourage verbalization of feelings and promote outlet for expression
• The delusion is paranoid disorder with delusions of reference (CIA)

Question 5

The nurse asks the client, “What brought you to the hospital?” The client’s response is, “The bus.” What type of thinking is this client exhibiting?

Answer 5

Concrete

• Literal thinking focused on the physical world; opposite of abstract thinking
• Focused on the facts in the here and now, physical objects, and literal definitions