A client diagnosed with schizophrenia disorder states, "Can't you hear them? It's the devil. The devil is telling me I'm going to hell." Which is the most appropriate nursing response?
"The voices must sound scary, but the devil is not talking to you. This is part of your illness."
"The devil only talks to people who are receptive to his influence."
"You are not going to hell. You are a good person."
"Did you take your medicine this morning?"
The Correct Answer is A
a. "The voices must sound scary, but the devil is not talking to you. This is part of your illness." Validating the experience ("The voices must sound scary") shows empathy and avoids dismissing the client's reality. Explaining it as part of the illness ("This is part of your illness") provides a non-judgmental explanation.
b. "The devil only talks to people who are receptive to his influence." Denying the voices can be dismissive and make the client feel isolated.
c. "You are not going to hell. You are a good person." While offering reassurance might seem comforting, it doesn't address the specific hallucination.
d. "Did you take your medicine this morning?" Medication is important, but the immediate priority is to address the hallucination and provide support.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
a. Sharing limited personal information: Sharing personal information can blur professional boundaries and make the client feel uncomfortable.
b. Being reliable, honest, and consistent during interactions: Predictability and consistency build trust, especially for someone with a condition that can distort reality.
c. Establishing personal contact with family members: Involving family members may not always be appropriate and could violate the client's privacy. It's best to proceed with the client's consent
d. Sitting close to the client to establish rapport: Sitting too close can be perceived as intrusive and might make the client feel uneasy.
Correct Answer is A
Explanation
a. Pulling out their hair (Correct): Trichotillomania is a mental health disorder characterized by the repetitive pulling out of one's hair. This behavior often serves as a way to cope with anxiety or negative emotions. It's the defining characteristic of the condition.
b. Pretending to be sick: Malingering, or pretending to be sick for secondary gain, is not a characteristic behavior of Trichotillomania.
c. Aphanie: Aphanie is a complete or partial loss of the sense of touch. It's not related to anxiety relief or Trichotillomania.
d. Amnesia: Amnesia is memory loss. While anxiety can be a contributing factor in some amnestic cases, it's not a behavior used to relieve anxiety.
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