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

Answer and Explanation

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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Correct Answer is C

Explanation

A. Incorrect. Mental health and mental illness are not the same concepts. Mental health refers to a person's emotional, psychological, and social well-being, while mental illness refers to specific mental health conditions that significantly affect a person's thoughts, emotions, and behaviors.

B. Incorrect. Mental health and mental illness can both present at any age. Mental health is a broader concept that encompasses overall well-being, while mental illnesses can manifest at various stages of life.

C. Correct. This statement accurately distinguishes between mental health and mental illness. Mental health involves the ability to cope with daily stressors, while mental illness is characterized by disruptions in activities of daily living due to specific mental health conditions.

D. Incorrect. This statement confuses the relationship between mental health and mental illness. Mental health is a broader concept that contributes to overall well-being, while mental illness is a specific condition that may arise due to various factors, including poor mental health.

A. Social isolation RUT inability to relate to others B. Risk for suicide R/T altered thought C. Altered sensory perception RUT increased levels of anxiety D. Risk for violence: directed toward others R/T suspicious thoughts

Correct Answer is D

Explanation

A. Social isolation R/T inability to relate to others

While social isolation may be a concern for individuals with paranoid personality disorder, the immediate safety risk associated with the disorder is more related to the potential for violence. Therefore, addressing the risk of violence takes precedence.

B. Risk for suicide R/T altered thought:

Paranoid personality disorder is not typically associated with a high risk of suicide. Individuals with this disorder are more likely to pose a risk to others due to their suspicious thoughts and mistrust. Suicide risk assessments are crucial but may not be the top priority in this specific case.

C. Altered sensory perception R/T increased levels of anxiety:

Paranoid personality disorder does involve heightened levels of anxiety, but altered sensory perception is not a primary characteristic of the disorder. Addressing anxiety is important, but the potential for violence toward others is a more immediate concern.

D. Risk for violence: directed toward others R/T suspicious thoughts:

This is the most appropriate priority. Individuals with paranoid personality disorder may have intense mistrust and suspicion, leading to the potential for aggressive or violent behavior directed toward others. Prioritizing safety and preventing harm to others is crucial in the care of clients with this disorder.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is discussing the difference between mental illness and mental health with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding?

Correct Answer is C

Explanation

Which nursing diagnosis should be prioritized when providing care to a client diagnosed with paranoid personality disorder?

Correct Answer is D

Explanation

Within the nurse's scope of practice, which function is exclusive to the advanced practice psychiatric nurse?

A client is diagnosed with bipolar disorder and admitted to an inpatient psychiatric unit. Which is the priority outcome for this client?

A withdrawn client diagnosed with schizophrenia expresses little emotion and refuses to attend group therapy. What altered component of the nervous system should a nurse recognize as being implicated in this behavior?

The patient admitted with antisocial disorder will display which symptom(s)?

A nurse is describing the concept of cultural competence to a newly licensed nurse. Which of the following examples should the nurse include?

A nurse on a mental health unit is caring for a client who has generalized anxiety disorder. The client received a telephone call that was upsetting and now the client is pacing up and down the corridors of the unit. Which of the following actions should the nurse take?

A client diagnosed with bipolar I disorder is distraught over insomnia experienced over the last 3 nights and a 12-pound weight loss over the past 2 weeks. Which should be this clients priority nursing diagnosis?