A nurse is caring for a client who has schizophrenia and begins to talk about fantasy subjects. Which of the following is an appropriate intervention by the nurse?
Encourage the client to focus on reality-based issues.
Ask the client to explain the meaning behind what he is saying.
Persuade the client that his thoughts are not true.
Allow the client to continue talking so as not to interrupt the delusion.
The Correct Answer is A
Choice A reason: Encouraging focus on reality-based issues helps redirect the client gently without reinforcing delusions. It maintains therapeutic communication while grounding the client.
Choice B reason: Asking for meaning focuses attention on the delusion, reinforcing it rather than redirecting.
Choice C reason: Persuading the client that thoughts are not true is confrontational and ineffective. Clients with schizophrenia may not accept reality testing when actively delusional.
Choice D reason: Allowing continued delusional talk reinforces psychosis and does not promote reality orientation.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Displaying disapproval toward the perpetrator is non-therapeutic. The nurse’s role is to support the client, not express personal judgment.
Choice B reason: Probing for details can retraumatize the client and may feel invasive. The nurse should allow the client to share at their own pace.
Choice C reason: Inviting family members may compromise the client’s safety and confidentiality, especially if the perpetrator is a family member.
Choice D reason: Being direct and honest fosters trust and helps the client feel safe. Clear communication is therapeutic and supports recovery.
Correct Answer is B
Explanation
Choice A reason: An overly friendly attitude may increase suspicion in a client with paranoia. A calm, neutral approach is more therapeutic.
Choice B reason: Allowing the client to unwrap food items helps reduce paranoia about tampering or poisoning. This intervention promotes trust and reduces anxiety.
Choice C reason: Using touch can be misinterpreted and increase paranoia or agitation. Physical contact should be avoided unless necessary for safety.
Choice D reason: Rotating staff frequently can increase mistrust. Consistency in caregivers helps build rapport and reduce paranoia.
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