A 28-year-old client with schizophrenia is pacing the hallway, appearing frightened and mumbling to themselves. When approached, the client states, "The voices are telling me the staff is trying to poison me." Based on this presentation, which of the following nursing interventions is most appropriate?

"I don’t hear the voices, but I understand they're real to you."

Engage in distraction by challenging the client’s beliefs with logical reasoning.

Avoid approaching the client to prevent reinforcing the hallucination.

"There are no voices. What you’re hearing isn’t real."

Answer and Explanation

The Correct Answer is A

Choice A reason: This response acknowledges the client’s experience without reinforcing the hallucination. It demonstrates empathy, maintains reality orientation, and builds trust, which are crucial therapeutic approaches.

Choice B reason: Challenging hallucinations with logic is not effective and can increase client defensiveness or distress. It may also escalate paranoia rather than reduce it.

Choice C reason: Avoiding the client ignores their distress and can increase isolation. Engagement is necessary to provide reassurance and therapeutic support.

Choice D reason: Directly denying the hallucination can invalidate the client’s experience, leading to mistrust and further paranoia. A more supportive acknowledgment is preferred.

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Correct Answer is A

Explanation

Choice A reason: The superego internalizes societal and parental standards of right and wrong. It guides moral development and can produce guilt when standards are violated or pride when they are upheld.

Choice B reason: The pleasure principle refers to the id, which seeks immediate gratification of desires without considering consequences. This does not describe the superego.

Choice C reason: The ego, not the superego, mediates between the id, superego, and external reality. It works on the reality principle to balance impulses with acceptable behavior.

Choice D reason: Defense mechanisms are managed by the ego, not the superego. They protect against anxiety but are not the superego’s primary function.

A. Assault. B. Malpractice. C. Negligence. D. False imprisonment.

Correct Answer is D

Explanation

Choice A reason: Assault involves creating fear of being harmed, not the actual restraint of a client without justification.

Choice B reason: Malpractice is professional misconduct related to deviation from standards of care, but it does not specifically describe unlawful confinement.

Choice C reason: Negligence is the failure to act with reasonable care, but it is generally unintentional and not classified as an intentional tort.

Choice D reason: False imprisonment occurs when a person is confined or restrained against their will without legal justification, which directly applies to restraining a client without consent or physician’s order.

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Naxlex Comprehensive Predictor Exams

According to psychoanalytic theory, which of the following best describes the role of the superego in personality development and mental health?

Correct Answer is A

Explanation

A nurse physically restrains a mentally ill client without obtaining proper consent or a physician's order, despite the client not posing an immediate threat to self or others. Which intentional tort could the nurse potentially be liable for?

Correct Answer is D

Explanation

Carl Rogers emphasized a humanistic approach in mental health nursing. Which of the following core concepts is central to his theory and therapeutic work?

The nurse is developing a plan of care for a 16-year-old client with bulimia nervosa. Which interventions would be included in the plan of care? (Select all that apply.)

A nurse is teaching a client at a prenatal clinic. The client shares that they have family members diagnosed with schizophrenia and wants to know how they can reduce their baby's risk of developing schizophrenia. Which of the following information should the nurse include?

The nurse assigned to care for the client with a diagnosis of histrionic personality disorder expects to observe which characteristics and behaviors?

A recently widowed client becomes tearful at a routine clinic visit and states, "I just can’t get over my spouse’s death." Which of the following by the nurse are appropriate? (Select all that apply.)

A nurse is providing education about strategies for a safety plan for a female client who is a victim of intimate partner violence. Which strategies should be included in the safety plan? (Select all that apply.)

A client with schizophrenia who has a history of paranoid delusions asks the nurse, "Are you giving me something to poison me?" The nurse knows the client is receiving an antipsychotic medication. Applying the ethical principle of veracity, which response by the nurse is most appropriate?

A patient diagnosed with schizophrenia tells the nurse, "The CIA is monitoring us through the fluorescent lights in this room. Be careful what you say." Which response by the nurse would be most therapeutic?