A nurse is caring for a client who has schizophrenia.
The client states, "The voices in my head are driving me crazy.”. Which of the following Questions should the nurse ask?
What are the voices saying to you?
Why are the voices talking to you?
Would you like to go to your therapy session now?
Have you missed your medication today?
The Correct Answer is A
Choice A rationale
Asking about the content of the voices helps the nurse assess for command hallucinations, which can pose a safety risk to the client or others. This open-ended question encourages the client to elaborate, providing crucial information about the severity, nature, and potential danger of the auditory stimuli, which is the primary goal of the assessment.
Choice B rationale
This question is counterproductive because it asks for a causal explanation that the client, due to their altered neurochemical state, cannot provide. It can also be perceived as challenging the reality of the client's experience, which invalidates their feelings and can damage the therapeutic relationship. This is not a therapeutic approach.
Choice C rationale
This redirects the conversation away from the client's immediate distress and the core issue of their hallucinations. While therapy is part of treatment, it may not be appropriate at this moment of crisis. The nurse’s priority is to first assess the immediate risk and support the client's immediate needs, before introducing another activity.
Choice D rationale
Asking about medication adherence can be perceived as accusatory and may cause the client to become defensive. While medication non-adherence can contribute to symptom exacerbation, the immediate priority is to assess the current risk level posed by the hallucinations, not to lecture the client about medication. This question is not therapeutic.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Histrionic personality disorder is characterized by a pervasive pattern of excessive emotionality and attention-seeking behavior. Individuals with this disorder often feel uncomfortable when not the center of attention and may use dramatic, theatrical, or seductive behaviors to attract others. They are not typically withdrawn or anxious in social settings.
Choice B rationale
Avoidant personality disorder is characterized by a pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation. The client's statements of becoming "extremely anxious in social gatherings" and never feeling "good enough" for coworkers are hallmark symptoms of this disorder. They actively avoid social situations to prevent rejection.
Choice C rationale
Obsessive-compulsive personality disorder is characterized by a preoccupation with orderliness, perfectionism, and mental and interpersonal control. Individuals with this disorder are often rigid and inflexible. They are not typically described as being socially anxious due to feelings of inadequacy, but rather due to a need for control.
Choice D rationale
Borderline personality disorder is characterized by a pervasive pattern of instability in interpersonal relationships, self-image, and emotions, and marked impulsivity. While individuals with this disorder may experience intense anxiety and fear of abandonment, their core features are related to instability, not a pervasive feeling of not being "good enough" in social settings. .
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}
Explanation
Why Safety Comes First
- The client presents with multiple red flags for physical abuse and neglect, including bruises in various stages of healing, a fracture, and concerning behavior around the adult child.
- Ensuring the client is in a safe environment is the top priority to prevent further harm and initiate protective interventions.
Why Nutritional Status Is Next
- The client reports limited food availability and has a low BMI (18.3), suggesting possible malnutrition.
- Addressing nutritional needs is essential for recovery and overall well-being, especially in older adults who are vulnerable to rapid health decline.
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