A nurse is conversing with a client diagnosed with schizophrenia.

Suddenly, the client expresses fear, stating, “I’m scared.

Can you hear that? The voices are instructing me to do awful things.” Which of the following responses from the nurse would be suitable?

Why do you believe you are hearing voices?

What are the voices instructing you to do?

You need to comprehend that there are no voices.

Are the voices familiar to you?

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Asking "Why do you believe you are hearing voices?" is not a suitable response because it challenges the client's reality and can make them feel defensive or invalidated. It's important to validate the client's experience and avoid questioning the reality of their hallucinations.

It can also imply that the client is somehow responsible for their hallucinations, which can be stigmatizing and distressing.

It's more helpful to focus on the content of the hallucinations and how they are affecting the client, rather than on the cause of the hallucinations.

Choice B rationale:

Asking "What are the voices instructing you to do?" is a suitable response because it allows the nurse to assess the content of the hallucinations and the potential for harm.

This information can be used to develop a safety plan and to help the client manage their symptoms.

It also demonstrates to the client that the nurse is taking their concerns seriously and is interested in understanding their experience.

Choice C rationale:

Telling the client "You need to comprehend that there are no voices" is not a suitable response because it is dismissive of the client's experience and can make them feel like they are not being heard or understood.

It's important to remember that hallucinations are very real to the person experiencing them, and telling them that they are not real is not helpful.

It can also damage the therapeutic relationship between the nurse and the client.

Choice D rationale:

Asking "Are the voices familiar to you?" is not a suitable initial response because it is not directly relevant to the client's safety or to the assessment of their symptoms.

While it may be helpful to gather information about the nature of the voices at some point, the priority is to assess the potential for harm and to develop a safety plan.

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Correct Answer is A

Explanation

Choice A rationale:

Pseudoparkinsonism is an extrapyramidal side effect (EPSE) of antipsychotic medications, particularly first-generation antipsychotics (FGAs) like haloperidol, that closely resembles the symptoms of Parkinson's disease. It's characterized by:

Stooped posture: A forward-leaning posture, often with rounded shoulders and a head that is bent forward.

Shuffling gait: Small, slow steps with reduced arm swing, often described as a "shuffling" or "dragging" walk.

Rigidity: Increased muscle stiffness throughout the body, leading to resistance to movement and a feeling of tightness.

Bradykinesia: Slowness of movement, both in initiating and completing actions.

Tremor: Involuntary shaking, often most noticeable in the hands, but can also affect the arms, legs, head, or jaw.

Masked facies: A decreased facial expression, often described as a "flat" or "expressionless" face.

Mechanism of pseudoparkinsonism:

Haloperidol primarily blocks dopamine D2 receptors in the nigrostriatal pathway of the brain.

Dopamine plays a crucial role in motor control, and its blockade in this pathway leads to a disruption in the balance of dopamine and acetylcholine, another neurotransmitter involved in movement.

This imbalance results in the characteristic symptoms of pseudoparkinsonism.

Risk factors for pseudoparkinsonism:

Older age

Female sex

Higher doses of antipsychotic medication

Prolonged use of antipsychotic medication

History of Parkinson's disease or other movement disorders

Presence of other EPSEs

Management of pseudoparkinsonism:

Dose reduction: If possible, the dose of the antipsychotic medication may be reduced.

Switching to a different antipsychotic: Some antipsychotics, such as second-generation antipsychotics (SGAs), have a lower risk of causing EPSEs.

Anticholinergic medications: These medications can help to counteract the effects of dopamine blockade on the acetylcholine system, but they can have their own side effects, such as dry mouth, constipation, and urinary retention.

Amantadine: This medication can also be used to treat pseudoparkinsonism, but it has the potential to cause side effects such as insomnia, anxiety, and livedo reticularis (a mottled skin rash).

A. Place the client in seclusion if she is experiencing visual hallucinations. B. Minimize staff supervision of the client’s interactions with others. C. Directly tell the client that delusions are not real. D. Limit the client’s participation in group activities.

Correct Answer is D

Explanation

The correct answer is D. Limit the client’s participation in group activities.

Explanation:

Clients with schizophrenia and paranoia may struggle in large group settings, where they could misinterpret interactions, feel threatened, or become agitated. Gradual integration into smaller, structured groups is typically recommended, rather than full exclusion, but limiting group participation can help reduce anxiety and prevent aggressive behaviors.

Why the other options are incorrect:

A. Place the client in seclusion if she is experiencing visual hallucinations – Seclusion is only used if the client poses a danger to themselves or others. Experiencing hallucinations alone does not warrant seclusion.
B. Minimize staff supervision of the client’s interactions with others – Increased supervision is necessary to ensure safety and monitor behavioral cues that may indicate escalating aggression.
C. Directly tell the client that delusions are not real – Confronting delusions outright can lead to agitation. Instead, acknowledge the client’s feelings while gently redirecting toward reality-based interactions.

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A nurse is conversing with a client diagnosed with schizophrenia. Suddenly, the client expresses fear, stating, “I’m scared. Can you hear that? The voices are instructing me to do awful things.” Which of the following responses from the nurse would be suitable?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has schizophrenia and is taking haloperidol. The nurse observes that the client has developed a stooped posture and shuffling gait. The nurse should document these findings as which of the following extrapyramidal side effects of haloperidol?

Correct Answer is A

Explanation

A nurse is contributing to the plan of care for a client who has schizophrenia and experiences paranoia with aggressive behavior. Which of the following interventions should the nurse recommend to be included in the plan of care?

Correct Answer is D

Explanation

Explanation:

Why the other options are incorrect:

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A nurse is conversing with a client diagnosed with schizophrenia.

Suddenly, the client expresses fear, stating, “I’m scared.

Can you hear that? The voices are instructing me to do awful things.” Which of the following responses from the nurse would be suitable?