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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is Choice A.
Choice A rationale:
Having consistent unit routines can provide a sense of stability and predictability, which can be beneficial for a client in the manic phase of bipolar disorder.
Choice B rationale:
Providing a stimulating environment can potentially exacerbate symptoms of mania, making it an inappropriate intervention.
Choice C rationale:
Scheduling daily seclusion times is not typically recommended as it can lead to feelings of isolation.
Choice D rationale:
Discouraging daytime napping can potentially lead to fatigue and worsen symptoms, so it’s not typically recommended.
Correct Answer is C
Explanation
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.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.