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 D
Explanation
Choice A Reason:
Nonverbal communication is a universal aspect of human interaction and plays a crucial role in all cultures. It includes gestures, facial expressions, body language, and other forms of communication that do not involve words. Understanding and interpreting nonverbal cues correctly is essential for nurses to provide culturally competent care.
Choice B Reason:
Culture significantly influences when and how clients seek medical care. Cultural beliefs can shape perceptions of health and illness, determine the types of treatments sought, and influence the level of trust in healthcare providers. Nurses must understand these cultural factors to provide effective and respectful care.
Choice C Reason:
It is unreasonable and culturally insensitive to expect clients to adapt to the care provided without consideration of their cultural background. Instead, healthcare providers should adapt their care to meet the cultural needs of their clients, ensuring that care is patient-centered and respectful of individual cultural practices.
Choice D Reason:
Focusing on clients' cultures rather than just their ethnicity allows nurses to provide more personalized and effective care. Culture encompasses a wide range of factors, including traditions, values, beliefs, and social norms, which can all impact health behaviors and needs. By understanding the cultural context of their clients, nurses can tailor their care approaches to better meet their clients' needs.
Correct Answer is C
Explanation
Choice A Reason:
Bureaucratic leadership is structured and rule-based, often relying on strict adherence to policies and procedures¹. In the scenario described, the nurse's decision to remove the patients from the group session does not necessarily reflect a bureaucratic approach, as it does not specify adherence to established rules or protocols.
Choice B Reason:
Democratic leadership involves participative decision-making, where the leader includes team members in the process¹. The nurse's action in the scenario does not suggest a democratic style, as the decision was made unilaterally without seeking input from the group.
Choice C Reason:
Autocratic leadership is characterized by individual control over all decisions with little input from group members¹. The nurse's decision to remove the patients without group discussion or input aligns with an autocratic leadership style.
Choice D Reason:
Laissez-faire leadership is a hands-off approach, where leaders allow group members to make the decisions¹. The nurse's proactive decision to remove the patients indicates a more direct and controlled approach, contrasting with the laissez-faire style.
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