During an Assessment,the Nurse Determines a Client Is Demonstrating Symptoms

question 4

Multiple Choice

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?
Select all that apply.

• A)The client says,The servants need to be disciplined."
• B)The client says,The voice told me to cut myself."
• C)The client laughs when asked about the health of a family member hospitalized for cancer treatment.
• D)The client asks to close the room door so that man can't get to me."
• E)The client says,I have not been able to get any sleep for months."

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Definitions:

Perilymph

The fluid that fills the space between the membranous labyrinth and the bony labyrinth of the inner ear.

Static Equilibrium

A state where an object is at rest, and all the forces acting upon it are balanced.

Maculae

Maculae are small, specialized regions in the sensory epithelia, notably in the vestibular system of the ear and the retina, involved in detecting balance and visual changes respectively.

Cristae

The folds of the inner membrane of mitochondria, where the electron transport chain takes place.