A client is noted to be pacing on the unit with their hands clenched and mumbling curses. The nurse knows that the initial approach to this client would be to:

stop the client in the hall and tell them that they must pace in the day room instead.

keep hands in pockets so as not to appear threatening.

speak softly and calmly,

offer the client a cup of coffee.

Answer and Explanation

The Correct Answer is C

a. Stop the client in the hall and tell them that they must pace in the day room instead. This can be confrontational and might escalate the situation.
b. Keep hands in pockets so as not to appear threatening. While non-threatening body language is important, the focus should be on verbal communication.
c. Speak softly and calmly. De-escalation is key in such situations. A calm and non-threatening approach is essential to build rapport and assess the situation.
d. Offer the client a cup of coffee. Stimulants like caffeine might worsen anxiety.

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Correct Answer is A

Explanation

a. "I can see that you are upset. Let's talk about ways to resolve this." This is correct because it validates the client's feelings, encourages problem-solving, and maintains the therapeutic milieu's principles of respect and support.
b. "I'll fix this right away. You need to calm down." This response does not encourage the client’s participation in resolving the issue and does not foster the therapeutic milieu's goal of client empowerment.
c. "Let's find a way to avoid this conflict in the future." While this promotes future problem-solving, it does not address the immediate concern or validate the client's current feelings.
d. "You should bring this up during group therapy later this week." This delays addressing the client's immediate concerns and might make the client feel unheard.

A. "The voices must sound scary, but the devil is not talking to you. This is part of your illness." B. "The devil only talks to people who are receptive to his influence." C. "You are not going to hell. You are a good person." D. "Did you take your medicine this morning?"

Correct Answer is A

Explanation

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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A client is noted to be pacing on the unit with their hands clenched and mumbling curses. The nurse knows that the initial approach to this client would be to:

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Naxlex Comprehensive Predictor Exams

A client diagnosed with schizophrenia, on an inpatient unit, approaches a nurse, stating, "Someone took my dinner! People need to respect others, and you need to do something about this now!" Which response by the nurse is guided by the basic assumption of the therapeutic milieu?

Correct Answer is A

Explanation

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?

Correct Answer is A

Explanation

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