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:
While interviewing is a component of the nursing process, specifically during the assessment phase, describing the nursing process solely as a method for interviewing is incomplete. The nursing process encompasses much more, including diagnosis, planning, implementation, and evaluation.
Choice B Reason:
This statement accurately reflects the purpose of the nursing process. It is a systematic method used by nurses to assist clients in adapting to stressors, whether they are physical, psychological, or social. The process involves assessing the client's needs, diagnosing issues, planning and implementing interventions, and evaluating the outcomes.
Choice C Reason:
The nursing process does play a role in minimizing allegations of negligence by providing a structured approach to care, but this is not its primary purpose. The main goal is to deliver individualized and effective care to clients, not just to protect against legal issues.
Choice D Reason:
Supporting a psychiatric diagnosis is part of the nursing process, but the statement is too narrow to describe the overall purpose. The nursing process is used to plan and provide personalized care, which goes beyond just supporting a diagnosis.
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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