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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Related Questions
Correct Answer is B
Explanation
a. "I may consider dating you once you have fully recovered." This response, while seemingly kind, is unprofessional. It creates a false sense of hope for the client and blurs the professional line.
b. "This is a professional relationship, and we need to be clear on that." This is a direct and professional way to set boundaries. It reminds the client of the nature of the relationship and avoids any misunderstanding.
c. "It's against hospital policy for me to date clients." While some hospitals might have such policies, this isn't always the case. A broader and more direct response like option b is preferable.
d. "I'm sorry, but I'm married and not interested in dating." This response might be true, but it focuses on the nurse's personal life and deflects from the professional aspect. Option b is more appropriate.
Correct Answer is D
Explanation
a. Clang association: Clang associations involve the use of words based on their sound rather than their meaning, often rhyming or having a similar sound. This pattern is not evident in the client’s response.
b. Word salad: Word salad refers to a jumble of words or phrases that lack logical coherence, which is not characteristic of the given response. The client's speech, while disorganized, still contains recognizable connections.
c. Ideas of reference: Ideas of reference involve the belief that common elements of the environment are directly related to oneself. This pattern is not shown in the client's response.
d. Loose association: Loose associations involve thoughts that are not logically connected to one another. The client’s response shows a series of loosely connected ideas, fitting the pattern of loose associations
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