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 C
Explanation
Choice A Reason:
Universality refers to the realization among group members that they are not alone in their experiences or feelings. While the interaction does show a shared experience, the primary factor demonstrated here is not just the commonality of experience but the encouragement and hope it provides.
Choice B Reason:
Imitative Behavior involves group members learning from each other by observing and copying behaviors. In this scenario, while the member who has been sober for 7 years may serve as a role model, the key element in this interaction is the hope conveyed through sharing personal success.
Choice C Reason:
Instillation of Hope is the encouragement that recovery is possible. The member's statement about overcoming multiple relapses and achieving long-term sobriety serves as a powerful testament to the possibility of recovery, thus instilling hope in others.
Choice D Reason:
Altruism is the unselfish concern for the welfare of others, which can be a byproduct of group therapy as members support each other. However, the primary factor at play in this scenario is the provision of hope rather than the act of giving support.
Correct Answer is ["B","C","D","E"]
Explanation
Choice A Reason:
Schizophrenia cannot be cured with antidepressants. Antidepressants may be used to treat comorbid depression in individuals with schizophrenia, but they do not address the core symptoms of schizophrenia itself. Schizophrenia is a chronic condition that typically requires lifelong treatment with antipsychotic medications to manage symptoms.
Choice B Reason:
Schizophrenia typically first presents in adolescence or early adulthood. This is the period when symptoms such as hallucinations, delusions, and disorganized thinking often first become apparent. The onset of schizophrenia during this developmental stage can significantly impact an individual's social and vocational abilities.
Choice C Reason:
Antipsychotic medications are the cornerstone of schizophrenia treatment. They can be used to manage symptoms of hallucinations and delusions, which are known as positive symptoms of schizophrenia. These medications work by affecting neurotransmitters in the brain, particularly dopamine.
Choice D Reason:
Individuals with schizophrenia have a higher risk of substance abuse disorders. Substance use can exacerbate symptoms of schizophrenia and complicate the course of the illness. It is important for treatment plans to address any co-occurring substance use disorders.
Choice E Reason:
Schizophrenia significantly affects thoughts and perceptions. It can cause distorted thinking patterns, false beliefs, and sensory experiences that others do not share. These symptoms can be distressing and may lead to difficulties in distinguishing reality.
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