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 B
Explanation
Choice A reason: Haloperidol may be used for severe agitation or hallucinations but is not the first-line treatment for delirium tremens because it does not address the underlying withdrawal process.
Choice B reason: Lorazepam, a benzodiazepine, is the drug of choice for managing alcohol withdrawal and delirium tremens. It reduces agitation, prevents seizures, and manages autonomic instability.
Choice C reason: Naltrexone is used to reduce alcohol cravings and prevent relapse but is not appropriate for acute withdrawal or delirium tremens.
Choice D reason: Disulfiram is an aversive therapy medication used to discourage alcohol consumption by causing unpleasant effects if alcohol is ingested. It is contraindicated during withdrawal due to safety risks.
Correct Answer is C
Explanation
Choice A reason: Assigning leadership in a group setting may overwhelm a patient with schizoid personality disorder, as they are uncomfortable with close social interactions. This approach could increase withdrawal.
Choice B reason: Confrontation about avoidance behaviors is not therapeutic. It may heighten resistance and increase distress rather than encourage trust or engagement.
Choice C reason: Structured one-on-one interactions allow the nurse to build rapport while respecting the patient’s preference for limited emotional involvement. This is the most appropriate approach for schizoid personality disorder.
Choice D reason: Forcing daily group therapy participation may cause stress and withdrawal, as these patients are more comfortable with solitary activities. Gentle encouragement, not insistence, is better suited.
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