A nurse is caring for a client who has schizophrenia and tells the nurse. "They lie about me all the time and they are trying to poison my food." Which of the following statements should the nurse make?
Why do you think you are being lied about and poisoned?"
You are mistaken. Nobody is lying about you or trying to poison you."
Who is lying about you and trying to poison you?"
You seem to be having very frightening thoughts."
The Correct Answer is D
A. "Why do you think you are being lied about and poisoned?": This question may come across as confrontational or challenging, potentially increasing the client's anxiety or defensiveness. It's important to acknowledge the client's feelings rather than questioning their beliefs directly.
B. "You are mistaken. Nobody is lying about you or trying to poison you.": This statement is dismissive and may cause the client to feel invalidated. It is crucial to acknowledge the client's feelings and experiences, even if they are not based on reality.
C. "Who is lying about you and trying to poison you?": This question may unintentionally reinforce the delusional thinking by suggesting that someone is indeed lying or trying to poison the client. It's essential to avoid validating or encouraging the delusional content.
D. "You seem to be having very frightening thoughts.": This statement acknowledges the client's emotions without directly challenging the delusional content. It shows empathy and creates an open and non-confrontational environment, allowing the client to express their feelings and experiences.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Risperidone (Risperdal):
Risperidone is an atypical antipsychotic and generally has a lower propensity for causing anticholinergic side effects compared to typical antipsychotics.
B. Lithium (Lithobid):
Lithium is a mood stabilizer used primarily for bipolar disorder and does not typically cause anticholinergic side effects.
C. Buspirone (Buspar):
Buspirone is an anxiolytic medication and does not have significant anticholinergic properties. It tends to have fewer side effects compared to other medications used for anxiety.
D. Fluphenazine (Prolixin):
Fluphenazine is a typical antipsychotic medication and belongs to the phenothiazine class, which is known to have notable anticholinergic effects. These effects can include dry mouth, constipation, blurred vision, urinary retention, and cognitive impairment.
Correct Answer is A
Explanation
A. Maintain consistency of care by open communication to avoid staff manipulation: This is the correct answer. Borderline personality disorder (BPD) clients may engage in splitting behaviors, which involve polarized views of staff as either all good or all bad. Maintaining consistency of care and open communication can help prevent manipulation and ensure fair and transparent interactions.
B. Maintain unit order by the application of autocratic leadership: Autocratic leadership, characterized by a top-down approach with limited input from others, may not be the most effective strategy in this situation. It may lead to resistance from clients and potentially escalate the conflict.
C. Allow the clients to apply the democratic process when developing unit rules: While democratic processes are generally beneficial, allowing clients to unreasonably demand modifications of unit rules without considering the overall impact on the therapeutic environment may not be appropriate. It's important to balance client involvement with maintaining a structured and therapeutic milieu.
D. Allow the client spokesperson to verbalize concerns during a unit staff meeting: While it's important to provide a platform for clients to express concerns, allowing a spokesperson to verbalize concerns during a staff meeting should be done in a manner that maintains order and follows the therapeutic goals of the unit. It should not involve unreasonably demanding modifications without a careful consideration of the impact on the overall treatment milieu.
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