Question

A nurse is performing a mental status examination for a newly admitted client. Which of the following client behaviors indicates impaired reality testing?

A) Delusions.
B) Command hallucinations.
C) Euphoria.
D) Flight of ideas.

Answer 1

Delusions are the client's behavior among the options provided that best indicates impaired reality testing during a mental status examination.

Step-by-step explanation:

A client's behavior that indicates impaired reality testing during a mental status examination is delusions. Delusions are fixed, false beliefs that are resistant to reason or confrontation with actual fact. This is distinct from hallucinations, which involve experiencing sensory events without real stimuli. Command hallucinations explicitly involve hearing voices that instruct the individual to perform actions, which although concerning, do not necessarily indicate impaired reality testing as directly as delusions do. Euphoria and flight of ideas, while indicative of mood and thought process disturbances respectively, do not directly reflect a client's ability to test reality.