A 16-year-old client diagnosed with schizophrenia disorder experiences command hallucinations to harm others. The client's parents ask a nurse, "Where do the voices come from?" Which is the appropriate nursing response?

"There is a chemical imbalance of the brain, which leads to altered perceptions."

"The hallucinations are caused by medication interactions."

"There is too little serotonin in the brain, causing delusions and hallucinations."

Abnormal hormonal changes have precipitated auditory hallucinations."

Answer and Explanation

The Correct Answer is A

a. "There is a chemical imbalance of the brain, which leads to altered perceptions." Schizophrenia is a complex mental health disorder with a strong biological component. While the exact cause is unknown, it's believed to involve abnormalities in brain chemistry and neurotransmitters. This is a general explanation that avoids going into too much detail but acknowledges the biological basis of hallucinations.
b. "The hallucinations are caused by medication interactions." Hallucinations are a core symptom of schizophrenia and not necessarily caused by medication interactions.
c. "There is too little serotonin in the brain, causing delusions and hallucinations." While serotonin might be involved in schizophrenia, it's not the only neurotransmitter implicated.
d. Abnormal hormonal changes have precipitated auditory hallucinations." Hormonal changes might influence mood, but they are not the primary cause of auditory hallucinations in schizophrenia.

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Correct Answer is B

Explanation

a. a client communicates significant distress. While significant distress is important to consider, it alone does not necessarily indicate a risk for developing mental illness unless it also impacts daily functioning and coping mechanisms.
b. maladaptive responses to stress are coupled with interference in daily functioning. This choice is correct because it reflects a combination of maladaptive coping (which can exacerbate mental health issues) and interference with daily functioning (a key indicator of mental illness according to DSM-5 criteria).
c. thoughts, feelings, and behaviors are not reflective of the DSM-5 criteria. While alignment with DSM-5 criteria is crucial for diagnosis, this choice alone does not address the risk aspect. The focus should be on behaviors that lead to impairment in daily functioning and coping.
d. a client uses defense mechanisms as ego protection. Using defense mechanisms is a normal part of human behavior and not necessarily indicative of mental illness risk unless these mechanisms are maladaptive and interfere with functioning.

A. Encourage alone time for the client in seclusion B. Assess one time for self-harm during treatment C. Discuss alternative coping strategies with the client D. Allow for unlimited discussion of physical symptoms

Correct Answer is C

Explanation

a. Encourage alone time for the client in seclusion: Encouraging alone time in seclusion may exacerbate feelings of isolation and is not typically recommended for clients with conversion disorder, who may benefit more from social support and therapeutic interventions.
b. Assess one time for self-harm during treatment: While assessing for self-harm is important, it is not specific to conversion disorder and should be part of routine nursing care for all clients, regardless of diagnosis.
c. Discuss alternative coping strategies with the client: This is correct because exploring alternative coping strategies can help the client manage stressors and symptoms associated with conversion disorder in healthier ways.
d. Allow for unlimited discussion of physical symptoms: Allowing unlimited discussion of physical symptoms may reinforce symptom focus and is not typically recommended in the treatment of conversion disorder, where the focus is on addressing underlying psychological distress.

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A 16-year-old client diagnosed with schizophrenia disorder experiences command hallucinations to harm others. The client's parents ask a nurse, "Where do the voices come from?" Which is the appropriate nursing response?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

At what point should the nurse determine that a client is at risk for developing mental illness? When:

Correct Answer is B

Explanation

A nurse is caring for a client who is diagnosed with a conversion disorder. What actions should the nurse include in the plan of care?

Correct Answer is C

Explanation

Which nursing behavior will enhance the establishment of a trusting relationship with a client diagnosed with schizophrenia disorder?

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