A nurse is reading the medical record for a client who has schizophrenia, which indicates that the client exhibits depersonalization. Which of the following statements by the client confirms that she is experiencing depersonalization?
"Everything in this room has changed and I don't recognize it anymore."
"I hear voices telling me that I have been bad."
"I have broken off all my past relationships because my friends and family are trying to kill me."
"My hands and feet are much smaller than they used to be."
The Correct Answer is D
Choice A reason: This statement reflects derealization, which is the experience that the external environment feels unreal or changed, not depersonalization.
Choice B reason: This describes auditory hallucinations, a common symptom of schizophrenia, but not depersonalization.
Choice C reason: This indicates persecutory delusions, not depersonalization.
Choice D reason: This confirms depersonalization, which involves altered perception of one’s own body or sense of self, such as believing body parts are distorted in size or shape.
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Correct Answer is B
Explanation
Choice A reason: Reflecting the patient’s feelings can be therapeutic in some cases, but here it could reinforce the delusion of being imprisoned rather than provide reassurance and grounding.
Choice B reason: This response provides reality orientation, reassurance, and therapeutic communication. It acknowledges the client’s concern while reinforcing the purpose of hospitalization, which is treatment and safety.
Choice C reason: Encouraging deep breathing addresses anxiety but does not respond to the client’s delusional thought. It avoids the core issue and may make the client feel dismissed.
Choice D reason: Asking “why” questions can feel confrontational and may heighten paranoia or mistrust. It does not provide therapeutic reassurance.
Correct Answer is B
Explanation
Choice A reason: While mood stabilizers are essential in treatment, medication cannot be safely administered before completing an assessment of risk and safety.
Choice B reason: The priority in this scenario is to assess safety, as John is at risk of harming himself or others due to reckless behavior during mania and suicidal ideation during depression. Safety always precedes treatment or education.
Choice C reason: Therapy is a valuable part of long-term management, but it is not the immediate priority when safety concerns exist.
Choice D reason: Education is important but cannot come before determining immediate risk and ensuring safety.
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