A client diagnosed with schizophrenia states, Can't you hear him? Its the devil. He's telling me I'm going to hell. Which is the most appropriate nursing reply?
Did you take your medicine this morning?
i'm sure the voices sound scary, I don't hear any voices speaking
The devil only talks to people who are receptive to his influence
You are not going to hell. You are a good person
The Correct Answer is B
A. "Did you take your medicine this morning?": While medication adherence is important, this response does not directly address the client's distress or validate their experience. It may come across as dismissive.
B. "I'm sure the voices sound scary, I don't hear any voices speaking.": This response acknowledges the client's experience without confirming or denying the presence of the voices. It expresses empathy and provides reassurance, fostering a therapeutic relationship.
C. "The devil only talks to people who are receptive to his influence": This response introduces a belief system that may not align with the client's reality and could be perceived as judgmental. It's important to avoid imposing personal beliefs on clients experiencing hallucinations.
D. "You are not going to hell. You are a good person": While expressing support and reassurance is positive, making definitive statements about the client's fate or goodness may not be helpful. It's more effective to acknowledge the distress without making absolute affirmations.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Allow the client to pace alone until physically tired: While pacing can be a coping mechanism, leaving the client alone may not be the most therapeutic approach. It is important for the nurse to provide support and assess the client's emotional state.
B. Walk with the client at a gradually slower pace: This is the correct answer. Walking with the client at a gradually slower pace allows the nurse to offer support and engage in therapeutic communication. It provides a calming presence and can assist the client in self-regulating their anxiety.
C. Have a staff member escort the client to her room: Escorting the client to her room might be perceived as restrictive or punitive. It is generally more beneficial to engage in supportive interventions and encourage coping strategies.
D. Instruct the client to sit down and stop pacing: Giving direct orders to stop pacing may increase anxiety and may not be an effective approach. It is often better to engage in a supportive manner and explore ways to help the client manage their anxiety.
Correct Answer is D
Explanation
A. "Why do you think you are being lied about and poisoned?": This question may come across as confrontational or challenging, potentially increasing the client's anxiety or defensiveness. It's important to acknowledge the client's feelings rather than questioning their beliefs directly.
B. "You are mistaken. Nobody is lying about you or trying to poison you.": This statement is dismissive and may cause the client to feel invalidated. It is crucial to acknowledge the client's feelings and experiences, even if they are not based on reality.
C. "Who is lying about you and trying to poison you?": This question may unintentionally reinforce the delusional thinking by suggesting that someone is indeed lying or trying to poison the client. It's essential to avoid validating or encouraging the delusional content.
D. "You seem to be having very frightening thoughts.": This statement acknowledges the client's emotions without directly challenging the delusional content. It shows empathy and creates an open and non-confrontational environment, allowing the client to express their feelings and experiences.
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