A client who has schizophrenia is talking to the nurse and states, "Do you hear that? I am scared. The voices are telling me to do horrible things which of the following responses by the nurse is appropriate?
"You need to understand there are no voices"
What are the voices telling you to do?
What do you think is causing you to heal the voices?
"You need to tell the forces to leave you alone.
The Correct Answer is B
a. "You need to understand there are no voices": Denying the client's experience can be invalidating and unhelpful.
b. What are the voices telling you to do? (Correct)A key principle in responding to someone experiencing auditory hallucinations is to validate their experience and ask open-ended questions. This helps the client feel heard and allows the nurse to assess the severity of the situation and potential safety risks.
c. What do you think is causing you to hear the voices? While exploring the cause of hallucinations can be part of therapy, in the immediate situation, focusing on what the voices are saying and assessing safety is more important.
d. "You need to tell the forces to leave you alone": This is confrontational and doesn't acknowledge the client's fear. It might also reinforce the belief in the voices having power.
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Naxlex Comprehensive Predictor Exams
Related Questions
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
Correct Answer is A
Explanation
a. "Focus on the feelings generated by the hallucinations and present reality." This approach validates the child's experience and feelings while gently orienting them to reality, which is a therapeutic communication technique.
b. "Ignore what they are saying, while attempting to discover the underlying cause." Ignoring the child’s statements can make them feel dismissed and could increase their distress. It is important to address their experience directly and compassionately.
c. "Present objective evidence that the voices are not real." Presenting objective evidence may not be effective as the child’s belief in the voices can be very strong, and this approach may lead to further agitation.
d. "Tell them to stop discussing the voices." This approach is dismissive and does not help the child manage their symptoms or feel understood. It is important to engage with the child’s experience constructively.
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