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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
a. Listen to the breath sounds in all lung fields: Assessing breath sounds is a more complex skill requiring a registered nurse's (RN) assessment.
b. Document the amount of output on the I & O sheet: Documenting intake and output (I&O) is a basic nursing task suitable for unlicensed nursing assistants (UNAs) under supervision.
c. Check the abdominal dressing for bleeding: Checking for bleeding requires a nurse's assessment due to the potential for complications.
d. Increase the IV fluid flow rate if the blood pressure is low: Adjusting IV fluids is a critical intervention requiring an RN's assessment and order.
Correct Answer is C
Explanation
a. Encourage alone time for the client in seclusion: Encouraging alone time in seclusion may exacerbate feelings of isolation and is not typically recommended for clients with conversion disorder, who may benefit more from social support and therapeutic interventions.
b. Assess one time for self-harm during treatment: While assessing for self-harm is important, it is not specific to conversion disorder and should be part of routine nursing care for all clients, regardless of diagnosis.
c. Discuss alternative coping strategies with the client: This is correct because exploring alternative coping strategies can help the client manage stressors and symptoms associated with conversion disorder in healthier ways.
d. Allow for unlimited discussion of physical symptoms: Allowing unlimited discussion of physical symptoms may reinforce symptom focus and is not typically recommended in the treatment of conversion disorder, where the focus is on addressing underlying psychological distress.
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