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 A

Explanation

A. Provide personal space to respect the client's boundaries: This is the correct answer. Personal space is crucial when caring for an agitated client with paranoia. Respecting the client's need for distance helps to reduce anxiety and prevent escalation of agitation.

B. Maintain continual eye contact throughout the interview: Continuous eye contact may be perceived as confrontational and can increase anxiety, especially in individuals with paranoia. It is important to be mindful of non-verbal cues and adapt the approach to the client's comfort level.

C. Provide neon lights and soft music: Introducing external stimuli like neon lights and music may not be appropriate for an agitated client with paranoia. It could potentially exacerbate their distress. The focus should be on creating a calm and non-threatening environment.

D. Use therapeutic touch to increase trust and rapport: While therapeutic touch can be beneficial in certain situations, it may not be suitable for a client experiencing paranoia. Touch can be perceived as intrusive and may escalate agitation in this context.

A. "Group therapy is an economical way of providing therapy to many clients concurrently." B. "Group therapy is optional. You can go if you find the topic helpful and interesting." C. Group therapy is mandatory. All clients must attend." D. "The purpose of group therapy is to learn and practice new coping skills.

Correct Answer is B

Explanation

A. "Group therapy is an economical way of providing therapy to many clients concurrently.": While this statement may be true, it does not directly address the client's concerns or provide information about the voluntary nature of group participation.

B. "Group therapy is optional. You can go if you find the topic helpful and interesting.": This is the correct answer. Acknowledging the client's autonomy and providing information about the voluntary aspect of group therapy respects the client's preferences and promotes a collaborative therapeutic relationship.

C. "Group therapy is mandatory. All clients must attend.": This statement is more authoritarian and does not take into account the individual needs and preferences of the client. It is important to involve clients in decisions about their treatment whenever possible.

D. "The purpose of group therapy is to learn and practice new coping skills.": While this statement provides information about the purpose of group therapy, it does not directly address the client's question about the optional nature of attendance.

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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 nursing intervention would be most appropriate when caring for an acutely agitated client with paranoia?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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