A charge nurse overhears another nurse talking with a client who has schizophrenia. Suddenly the client yells, "I am the devil! I am God! Open the gate for me!" Which of the following replies by the nurse requires intervention?

"There is no gate for me to open."

"I don't understand. Can you tell me what that means?"

"Are you saying that you are both good and bad?"

"It sounds frightening to feel like both God and the devil at the same time."

Answer and Explanation

The Correct Answer is A

Choice A Reason:
This response may invalidate the client's experience and can be perceived as dismissive of the client's delusional thoughts. It does not acknowledge the client's current reality or provide any therapeutic communication. An intervention is required to guide the nurse in offering a more empathetic and validating response.

Choice B Reason:
Asking the client to clarify what they mean encourages communication and shows a willingness to understand the client's perspective. It is a therapeutic approach that can help the nurse gain insight into the client's thoughts and provide appropriate support.

Choice C Reason:
This response could potentially validate the client's delusional thinking by engaging in the content of the delusion. It might lead to further discussion about the delusion rather than redirecting the client to reality, which could be counterproductive.

Choice D Reason:
Expressing empathy by acknowledging that the client's feelings must be frightening is a therapeutic response. It validates the client's emotions without confirming the delusional content and can help the client feel understood and supported.

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Correct Answer is A

Explanation

Choice A Reason:
Providing continuity of care by assigning the same staff is essential in creating a therapeutic environment. It allows for the development of trust and rapport, which are foundational for effective mental health treatment. Consistent caregivers can better understand the clients' needs and tailor interventions accordingly.

Choice B Reason:
While it is important to be open to discussing various topics, the nurse must ensure that discussions remain therapeutic and relevant to treatment goals. Some topics may need to be redirected or limited to maintain a safe and supportive environment.

Choice C Reason:
Allowing clients to determine the boundaries of the nurse-client relationship could lead to blurred lines that may affect the quality of care. It is the nurse's responsibility to establish clear professional boundaries while being empathetic and supportive.

Choice D Reason:
Focusing on client wellness is a broad concept that encompasses the clients' physical, mental, and social well-being. It is a goal of the therapeutic environment to promote overall wellness, but specific strategies are needed to achieve this aim.

A. Laughs when watching a sad movie. B. Maintains an immobilized state for several hours. C. Refuses to eat any unwrapped foods. D. Uses a rhyming form of speech.

Correct Answer is B

Explanation

Choice A Reason:
Laughing inappropriately, such as when watching a sad movie, can be a symptom of schizophrenia, but it is not specific to the catatonic subtype. Inappropriate affect may occur in schizophrenia but does not solely characterize catatonic behavior.

Choice B Reason:
Catatonic schizophrenia is marked by periods of immobility or stupor. A client who maintains an immobilized state for several hours is displaying a classic sign of catatonia. During these periods, the client may be mute, rigid, and resistant to movement, which are key features of this condition.

Choice C Reason:
Refusing to eat certain types of food is not specifically indicative of catatonic schizophrenia. While individuals with schizophrenia may have unusual preferences or fears related to food, this behavior could be related to a variety of factors and is not a definitive sign of catatonia.

Choice D Reason:
Using a rhyming form of speech, known as clang associations, can be seen in schizophrenia but is more characteristic of disorganized thinking associated with the disorder rather than catatonia. Catatonia involves motoric symptoms rather than speech patterns.

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A charge nurse overhears another nurse talking with a client who has schizophrenia. Suddenly the client yells, "I am the devil! I am God! Open the gate for me!" Which of the following replies by the nurse requires intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a group of clients on a mental health unit. Which of the following actions should the nurse plan to take to create a therapeutic environment?

Correct Answer is A

Explanation

The nurse is caring for a newly admitted client diagnosed with catatonic schizophrenia. Which of the following behaviors should the nurse document to be consistent with catatonic schizophrenia? The client:

Correct Answer is B

Explanation

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