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."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Waiting for the client to initiate interaction may result in missed opportunities to build trust and rapport. Clients who are suspicious may never feel comfortable enough to initiate interaction, which could hinder their care and treatment.
Choice B reason:
Adopting a neutral attitude when providing care is recommended for clients who are suspicious. It helps to establish a non-threatening environment and conveys a sense of respect for the client's need for space and boundaries.
Choice C reason:
Disclosing personal information to demonstrate approachability can backfire with clients who are suspicious. It may be perceived as intrusive or as an attempt to elicit personal information from them in return.
Choice D reason:
Approaching the client frequently throughout the day for brief interactions might overwhelm and increase the client's suspicion. It's important to respect the client's space and allow them to set the pace for interactions.
Correct Answer is A
Explanation
Choice A reason:
Occupational therapists are trained to help individuals develop or regain the skills needed for daily living and working. They are particularly adept at assisting clients with work-related skills, making them an ideal choice for this client's plan of care.
Choice B reason:
While psychiatrists are essential for diagnosing and treating mental health conditions, their role is less focused on teaching work-related skills and more on managing the client's psychiatric treatment.
Choice C reason:
Social workers provide valuable support in connecting clients with community resources and supporting their psychosocial needs. However, they do not typically specialize in teaching work-related skills.
Choice D reason:
Psychologists may work with clients to address cognitive or emotional barriers to employment, but they do not typically provide hands-on training in work-related skills as occupational therapists do.
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