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."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: The unconscious mind, according to psychoanalytic theory, is where repressed emotions, memories, and desires are stored. These hidden influences affect behavior and mental health without the individual’s conscious awareness.
Choice B reason: Active and current awareness of memories and thoughts describes the conscious mind, not the unconscious.
Choice C reason: Immediate awareness of sensory input and decision-making refers to the conscious and preconscious processes, not the unconscious.
Choice D reason: Voluntary motor control and coordination involve the motor cortex and cerebellum, unrelated to psychoanalytic concepts of the unconscious.
Correct Answer is C
Explanation
Choice A reason: Rationalization involves creating logical explanations to justify behavior or feelings. In this case, the client is not justifying but outright rejecting the diagnosis, so this does not apply.
Choice B reason: Regression occurs when an individual reverts to earlier developmental behaviors, such as childish actions, to cope with stress. The client is not reverting to earlier behaviors but refusing to accept reality.
Choice C reason: Denial is the refusal to accept reality or facts, blocking external events from conscious awareness. The client’s insistence that the diagnosis is a mistake demonstrates denial, making this the correct defense mechanism.
Choice D reason: Projection occurs when a person attributes their unacceptable thoughts or feelings to someone else. The client is not attributing their illness to others but rejecting its existence altogether.
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