A nurse is caring for a client who is experiencing auditory hallucinations.
What should the nurse say first?

“I know you hear the voices, but I do not.”

“How often do you hear the voices?”

“What are the voices telling you?”

“The voices are part of your illness.”

Answer and Explanation

The Correct Answer is C

The correct answer is Choice C.

Choice A rationale: While acknowledging the client's experience is important, this statement does not immediately address the content of the hallucinations, which could be crucial for assessing the client's safety.

Choice B rationale: Asking how often the client hears the voices is useful information for later, but it is not the immediate priority when first addressing auditory hallucinations.

Choice C rationale: Asking what the voices are telling the client is the priority. This helps the nurse assess if the hallucinations include commands or harmful content, which is essential for determining the client's immediate safety and risk of self-harm or harm to others.

Choice D rationale: Explaining that the voices are part of the client's illness can be useful for long-term understanding, but it does not address the immediate need to assess the content of the hallucinations.

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Correct Answer is A

Explanation

Answer and explanation

Choice A rationale:

Impaired judgment is a cognitive symptom of schizophrenia, not a positive symptom. It involves difficulties with decisionmaking, problem-solving, and understanding consequences. While it's a significant feature of schizophrenia, it doesn't reflect an excess or distortion of normal functions, which is the hallmark of positive symptoms.

Choice B rationale:

Dysphoria refers to a depressed mood or a state of unhappiness and dissatisfaction. It's a negative symptom of schizophrenia, characterized by a decrease or absence of normal functions. It's not considered a positive symptom as it doesn't involve an excess or distortion of normal processes.

Choice C rationale:

Disorganized speech is a hallmark positive symptom of schizophrenia. It involves significant disruptions in the way a person speaks and communicates. It can manifest in several ways, including: Derailment: Abrupt shifts in topic without logical connection

Tangentiality: Responding to questions in irrelevant or oblique ways

Incoherence: Speech that is fragmented and difficult to understand

Loose associations: Combining words or phrases in a way that lacks logical sense

Neologisms: Creating new words or phrases that have meaning only to the speaker

Word salad: Severely disorganized speech that is essentially incomprehensible

Disorganized speech is considered a positive symptom because it reflects an excess or distortion of normal speech processes. It's a core feature of schizophrenia and often has a significant impact on communication and social functioning.

Choice D rationale:

Anhedonia is the inability to experience pleasure. It's a negative symptom of schizophrenia, characterized by a decrease or absence of normal emotional responses. It's not considered a positive symptom as it doesn't involve an excess or distortion of normal processes.

A. “You really should work hard to stay on the schedule we establish here.” B. “I wouldn’t worry about what you’ve done in the past. C. You’ll do just fine this time.” D. “Why do you find it difficult to take your medications if they improve your condition?”

Correct Answer is D

Explanation

The correct answer is Choice D.

Choice A rationale: Telling the client to work hard to stay on the schedule does not address the underlying reasons for the client's difficulty in following a medication regimen and may come off as dismissive.

Choice B rationale: Saying not to worry about the past does not acknowledge the client's concerns and may not provide practical assistance for future adherence.

Choice C rationale: Offering reassurance without addressing the client's past challenges does not provide a concrete plan for improving adherence.

Choice D rationale: Asking the client why they find it difficult to take medications opens a dialogue that allows the nurse to understand the client's specific barriers and to provide tailored strategies to improve adherence. This response is empathetic and solution-focused.

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A nurse is caring for a client who is experiencing auditory hallucinations. What should the nurse say first?

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A nurse is caring for a client who is experiencing auditory hallucinations.
What should the nurse say first?