A nurse is caring for a client who has schizophrenia. The client states, "They lie about me all the time and are trying to poison my food." Which of the following responses should the nurse make?
"You seem to be having some very frightening thoughts."
"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?"
The Correct Answer is A
Choice A reason: This response acknowledges the client's feelings without agreeing with the delusion or challenging their reality, which can help in building trust and rapport.
Choice B reason: Asking "Why do you think you are being lied about and poisoned?" could potentially reinforce the delusion and lead the client to further justify their beliefs.
Choice C reason: Directly telling the client they are mistaken can be confrontational and may damage the therapeutic relationship.
Choice D reason: Asking "Who is lying about you and trying to poison you?" can validate the delusion and is not a therapeutic response.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","E","F"]
Explanation
Choice A reason: Telling the patient everything will be okay is not an appropriate intervention as it does not address the specific educational needs related to their knowledge deficit.
Choice B reason: Including family members in teaching can provide additional support and help reinforce the information provided to the patient.
Choice C reason: Identifying knowledge deficiencies is essential to tailor the education to the patient's specific needs.
Choice D reason: Providing written and verbal materials can help the patient understand and remember the information about their surgery and care.
Choice E reason: Determining the patient's anxiety levels can help the nurse address any concerns or fears that may affect their learning.
Choice F reason: Documenting patient understanding and teaching provided is important for continuity of care and to ensure that the patient has received and understood the necessary information.
Correct Answer is B
Explanation
Choice A reason: While relaxation techniques are beneficial, providing structure is often the first step in helping clients with OCD manage their symptoms, as it can reduce anxiety and prevent time for obsessions and compulsions to occur.
Choice B reason: A structured schedule can help the client focus on tasks and activities, reducing the time available for obsessive thoughts and compulsive behaviors.
Choice C reason: Identifying expectations is important, but it should come after establishing a structured routine that can support the client's participation in care.
Choice D reason: Discussing alternative coping strategies is a part of treatment, but initially providing a structured schedule can offer immediate relief and a sense of control for the client.
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