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.
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Correct Answer is B
Explanation
Choice A reason: Enhancing dopamine transmission is not the mechanism of antipsychotics; excessive dopamine is implicated in schizophrenia’s positive symptoms, so reducing—not enhancing—dopamine activity is key.
Choice B reason: Blocking both dopamine and serotonin receptors is characteristic of second-generation (atypical) antipsychotics. This dual action reduces extrapyramidal side effects while still targeting positive and negative symptoms.
Choice C reason: First-generation antipsychotics primarily block dopamine D2 receptors, which increases the risk for extrapyramidal side effects such as dystonia and parkinsonism.
Choice D reason: Selective serotonin receptor blockade is not the defining mechanism of second-generation antipsychotics. These medications act on both dopamine and serotonin systems.
Correct Answer is A
Explanation
Choice A reason: The M’Naghten Rule requires proof that, due to mental illness, the person did not understand the nature of the act or could not distinguish right from wrong at the time of the offense. This is the key standard used in many jurisdictions for insanity defenses.
Choice B reason: Having a history of mental illness alone is not sufficient; the rule focuses on the client’s mental state during the offense, not prior diagnoses.
Choice C reason: Being driven by uncontrollable impulses is not part of the M’Naghten criteria. This falls more under the “irresistible impulse” test, which is separate.
Choice D reason: Intoxication, even if it impairs judgment, does not qualify under the M’Naghten Rule. Voluntary substance use generally excludes insanity defenses.
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