A nurse is caring for a client diagnosed with schizophrenia and is experiencing hallucinations. Which of the following actions should the nurse take?

Ask the client direct questions about the hallucination.

Act to the client as if the hallucination is real.

Tell the client to go to their room and they should go away.

Instruct the client to argue with the voices that are a part of the hallucination.

Answer and Explanation

The Correct Answer is A

The correct answer is choice A. Ask the client direct questions about the hallucination.

Choice A rationale:

Asking direct questions about the hallucination helps the nurse understand the client’s experience and assess the content and intensity of the hallucinations. This approach also allows the nurse to provide appropriate support and interventions.

Choice B rationale:

Acting as if the hallucination is real can reinforce the client’s distorted perception of reality, which is not therapeutic. The nurse should acknowledge the client’s experience without validating the hallucination as real.

Choice C rationale:

Telling the client to go to their room and that the hallucinations should go away is dismissive and does not address the client’s immediate needs. It is important to engage with the client and provide support rather than dismiss their experience.

Choice D rationale:

Instructing the client to argue with the voices can increase the client’s distress and is not a recommended therapeutic approach. Instead, the nurse should help the client find ways to cope with and manage the hallucinations.

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Correct Answer is D

Explanation

Choice A rationale:

Periods of elation with unusual talkativeness. Rationale: While periods of elation with unusual talkativeness can be associated with certain mental health conditions, such as bipolar disorder, they are not specific to schizophrenia. These symptoms are more indicative of mania, which is characteristic of bipolar disorder.

Choice B rationale:

Recurrent thoughts of past trauma. Rationale: Recurrent thoughts of past trauma can be associated with various mental health disorders, including post-traumatic stress disorder (PTSD), but they are not specific to schizophrenia. Schizophrenia is primarily characterized by disturbances in thought processes, perception, and behavior.

Choice C rationale:

Preoccupied with folding clothes. Rationale: Preoccupation with folding clothes is not a hallmark symptom of schizophrenia. Schizophrenia is characterized by symptoms such as hallucinations, delusions, disorganized thinking, and impaired social functioning.

Choice D rationale:

Invents words that have no meaning. Rationale: This statement is correct. Inventing words that have no meaning, also known as "neologisms," is a symptom often observed in individuals with schizophrenia. Neologisms are a manifestation of disorganized thinking and communication.

A. "You should try to see your partner's point of view before your own.” B. "Relationship difficulties are stressful and require effort to resolve.” C. "We could develop a plan for how to talk about this with your partner.” D. "Tell me more about the concerns that you have regarding your marriage.”

Correct Answer is A

Explanation

Choice A rationale:

Similar to the explanation in , this statement requires intervention. It reflects a judgmental and prescriptive approach, which is not conducive to a therapeutic conversation. It implies that the nurse knows what the client should do, undermining the client's autonomy and self-discovery process.

Choice B rationale:

Recognizing that relationship difficulties are stressful and require effort to resolve is a valid and supportive statement. It acknowledges the challenges the client is facing and does not impose a specific solution.

Choice C rationale:

Suggesting the development of a communication plan is a proactive and therapeutic response. It empowers the client to work collaboratively toward improving their marital situation.

Choice D rationale:

Encouraging the client to share more about their concerns promotes open communication and allows the nurse to better understand the client's perspective. This response is client-centered and supportive.

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A nurse is caring for a client diagnosed with schizophrenia and is experiencing hallucinations. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client diagnosed with schizophrenia. Which of the following behaviors should the nurse document to be associated with schizophrenia?

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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