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 A
Explanation
Choice A Reason:
Offering false reassurance occurs when a nurse or healthcare provider dismisses a patient's concerns with general comforting statements without addressing the reality of the situation or the patient's feelings. In this case, the nurse's response of "Don't worry, no one will harm your family" is an attempt to alleviate the patient's anxiety without acknowledging the patient's fear or providing a realistic plan to ensure the safety of the patient's family. This type of communication can undermine trust and prevent the patient from feeling heard and supported.
Choice B Reason:
Offering sympathy involves sharing feelings of pity or sorrow for someone else's misfortune. While the nurse's response may seem sympathetic, it does not directly express shared emotions or an understanding of the patient's distress. Therefore, it does not represent offering sympathy as a communication breakdown in this context.
Choice C Reason:
Providing a passive response would involve the nurse not actively engaging with the patient's concerns or failing to provide any response. Since the nurse in the scenario does respond to the patient's statement, this does not constitute a passive response.
Choice D Reason:
Showing disapproval would involve the nurse expressing judgment or criticism of the patient's feelings or actions. The nurse's response does not contain elements of judgment or criticism; rather, it is an attempt to reassure the patient, albeit falsely.
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.
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