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?
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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Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is D
Explanation
Choice A rationale:
Mental separation from distractions during painting is a healthy coping mechanism, allowing for focus and mindfulness.
It falls under the adaptive defense mechanism of compartmentalization, which involves temporarily separating thoughts and emotions to manage stress effectively.
It doesn't deny or distort reality, but rather creates a temporary mental space for relaxation and creativity.
Choice B rationale:
Writing a short story about a heroic woman is a form of sublimation, channeling negative emotions into a productive and creative outlet.
It's a mature defense mechanism that allows for indirect expression of anger or frustration without causing harm to oneself or others.
It can lead to personal growth and insight, as it encourages reflection and exploration of emotions through storytelling.
Choice C rationale:
Inability to recall the scene of a traumatic event is likely a dissociative defense mechanism, protecting the individual from overwhelming psychological distress.
It's a common response to trauma, and while it may be maladaptive in the long term if it prevents processing the trauma, it serves a protective function in the acute phase.
It doesn't necessarily indicate a maladaptive coping style overall, but rather a specific response to a traumatic experience.
Choice D rationale:
Declaring disinterest in work after being denied a promotion exemplifies disengagement, a maladaptive coping mechanism involving withdrawal and apathy.
It reflects an inability to cope with disappointment or setbacks in a constructive way.
It can lead to social isolation, decreased motivation, and potentially depression or other mental health issues.
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