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

Your child has a chemical imbalance of the brain, which leads to altered thoughts

Your child's hallucinations are caused by medication interactions

your child has too little serotonin in the brain causing delusions and hallucinations

your child's abnormal hormonal changes have precipitated auditory hallucinations

Answer and Explanation

The Correct Answer is A

A. Your child has a chemical imbalance of the brain, which leads to altered thoughts: This is the correct answer. It acknowledges the role of a chemical imbalance in the brain contributing to altered thoughts and hallucinations in the context of schizophrenia.

B. Your child's hallucinations are caused by medication interactions: This explanation is not likely in this context. While medications can have side effects, command hallucinations in schizophrenia are primarily related to the underlying disorder.

C. Your child has too little serotonin in the brain causing delusions and hallucinations: While serotonin is involved in mood regulation, attributing hallucinations solely to low serotonin levels oversimplifies the complex neurobiology of schizophrenia.

D. Your child's abnormal hormonal changes have precipitated auditory hallucinations: Hormonal changes are not considered a primary cause of auditory hallucinations in schizophrenia. The emphasis is on neurobiological and genetic factors influencing brain function.

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Correct Answer is B

Explanation

A. Incorrect. Falling asleep in the chair and refusing to eat lunch is not indicative of tardive dyskinesia (TD). TD is characterized by involuntary movements, not by changes in sleep patterns or appetite.

B. Correct. Grimacing and lip smacking are characteristic movements associated with tardive dyskinesia. TD is a side effect of long-term use of typical antipsychotic medications, and it involves involuntary, repetitive movements, often involving the face and mouth.

C. Incorrect. Excessive salivation and drooling are not specific to tardive dyskinesia. These symptoms may occur due to various reasons, and TD is primarily associated with abnormal, involuntary movements.

D. Incorrect. Experiencing muscle rigidity and tremors is more characteristic of other side effects or conditions, such as extrapyramidal symptoms, but it is not specific to tardive dyskinesia. TD typically involves repetitive, involuntary movements rather than tremors.

A. Challenge the patient at all times and remen in control of the situation B. Provide clear and straight forward communication C. Hold person accountability for their actions D. Remain consistent E. Avoid being too nice or friendly.

Correct Answer is ["B","C","D"]

Explanation

A. Challenge the patient at all times and remain in control of the situation:

Explanation: While maintaining a therapeutic boundary and structure is essential, challenging the patient at all times may lead to resistance or defensiveness. Collaborative and supportive approaches are often more effective than confrontational ones.

B. Provide clear and straightforward communication:

Explanation: Individuals with personality disorders may struggle with interpersonal relationships and communication. Clear and straightforward communication helps to minimize misunderstandings and establish a therapeutic environment.

C. Hold persons accountable for their actions:

Explanation: Accountability promotes responsibility and encourages individuals with personality disorders to take ownership of their behaviors. Setting clear expectations and consequences can be beneficial in fostering a sense of responsibility.

D. Remain consistent:

Explanation: Consistency in approach, rules, and expectations is crucial when working with individuals with personality disorders. It helps establish a stable and predictable environment, promoting a sense of security for the individual.

E. Avoid being too nice or friendly:

Explanation: Avoiding being too nice or friendly doesn't mean being unkind or dismissive. A balanced and professional approach, combining empathy with clear boundaries, is more beneficial. Being overly nice or friendly may blur professional boundaries and hinder therapeutic progress.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which behavior displayed by a patient receiving a typical antipsychotic medication would be assessed as displaying behaviors characteristic of tardive dyskinesia (TD)?

Correct Answer is B

Explanation

When working with individuals who have a personality disorder. The nurse is aware of the importance of incorporating which nursing measures. (Select all that apply).

Correct Answer is ["B","C","D"]

Explanation

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