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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: The 'thinking/content of thought' section of the Mental Health Status Examination assesses the logical process of thought, presence of delusions, obsessions, and preoccupations.
Choice B reason: 'Memory' assesses the person's ability to recall past events, which is not directly related to their current thought content.
Choice C reason: 'Judgment' evaluates the ability to make reasoned decisions, which, while important, is distinct from the content of thought.
Choice D reason: 'Speech and the ability to communicate' assesses the clarity, relevance, and coherence of speech, not the internal thought process.
Correct Answer is D
Explanation
Choice A reason: Thinking/content of thought refers to the logical process of thought and coherence, not directly to the experience of reality.
Choice B reason: Mood and affect pertain to the emotional state and its expression, not the perception of reality.
Choice C reason: Judgment involves decision-making abilities and the evaluation of situations, not the perception of reality.
Choice D reason: Perception is the component that deals with how a person experiences reality, including any hallucinations or delusions they may have.
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