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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "I can see that you are angry. Let's discuss ways to approach Peter with your concerns."
This response is empathetic and invites the client to discuss their concerns. However, it doesn't explicitly address the client's request for the nurse to take action. The more appropriate approach would involve the nurse taking direct responsibility for addressing the issue.
B. "Why are you overreacting to the issue?"
This response may be perceived as dismissive and judgmental. It does not validate the client's concerns or address the issue constructively.
C. "You should bring this to the attention of your treatment team."
While involving the treatment team is important, the client has directly approached the nurse with a concern. It is appropriate for the nurse to take the initial step in addressing the issue directly rather than immediately redirecting the client to the treatment team.
D. "I'll talk to Peter and present your concerns."
This is the most appropriate response. It acknowledges the client's concerns, takes responsibility for addressing the issue, and ensures that the client's voice is heard. The nurse can discuss the matter with Peter and work towards a resolution.
Correct Answer is C
Explanation
Individuals with OCD often engage in compulsive behaviors, such as repetitive cleaning, as a way to alleviate or decrease anxiety associated with obsessive thoughts. In the context of OCD, obsessions are intrusive and distressing thoughts, images, or urges that cause significant anxiety, while compulsions are repetitive behaviors or mental acts performed in response to the obsessions.
A. Decrease the time available for interaction with people:
While individuals with OCD may isolate themselves due to their symptoms, the primary motivation for repetitive behaviors like cleaning is to manage anxiety, not necessarily to avoid interaction with others.
B. Prevent aggressive and impulsive behaviors:
OCD compulsions are not typically aimed at preventing aggressive or impulsive behaviors. They are driven by the need to reduce distress related to obsessive thoughts.
C. Decrease anxiety:
This is the correct answer. Compulsive behaviors in OCD are often ritualistic actions performed to reduce the anxiety associated with obsessive thoughts. Cleaning, in this case, is a way for the individual to feel a sense of control and alleviate anxiety.
D. Manipulate others
The primary motive behind OCD compulsions is to manage personal anxiety, not to manipulate others. Individuals with OCD often recognize that their compulsions are excessive or irrational, but they feel driven to perform them to alleviate anxiety.
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