A nurse is talking with a client diagnosed with schizophrenia. Suddenly the client states, "I'm frightened. Do you hear that? The voices are telling me to do terrible things." Which of the following responses by the nurse is appropriate?

"You need to tell the voices to leave you alone.”

"You need to understand that there are no voices.”

"What are the voices telling you to do?”

"Why do you think you are hearing the voices?”

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Instructing the client to tell the voices to leave them alone oversimplifies the situation. It disregards the distress and lack of control that individuals with schizophrenia often experience when hearing voices. This response may also imply that the client has complete control over the voices, which is not accurate.

Choice B rationale:

Denying the existence of the voices contradicts the client's experience and could lead to further distrust between the client and nurse. Acknowledging the client's feelings and experiences is essential for building rapport and understanding in a therapeutic relationship.

Choice C rationale:

This response is appropriate because it acknowledges the client's experience and seeks to understand the content and nature of the voices. It demonstrates empathy and encourages open communication, which is crucial in providing effective care for individuals with schizophrenia.

Choice D rationale:

Asking the client why they think they are hearing the voices might be interpreted as confrontational or judgmental. It could make the client defensive and hinder open communication. Instead, focusing on the content of the voices allows the nurse to gain insight into the client's experiences without placing blame.

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Correct Answer is B

Explanation

The correct answer is choice B: "Tell me more about your concerns about taking chemotherapy."

Choice A rationale:

This response focuses on negative outcomes and might discourage the client from exploring her options. It does not support the client's autonomy or address her concerns about nontraditional treatments. The nurse's role should be to facilitate open communication and understanding.

Choice B rationale:

This response is the most therapeutic. By inviting the client to share her concerns, the nurse demonstrates empathy and encourages the client to express her thoughts and feelings. This approach fosters a collaborative and respectful relationship, allowing the nurse to address the client's worries effectively.

Choice C rationale:

This response is directive and dismissive of the client's wishes. It fails to consider the client's perspective and autonomy. The nurse should avoid imposing personal opinions and instead promote a patient-centered approach.

Choice D rationale:

While acknowledging the provider's expertise is important, this response does not address the client's concerns about nontraditional treatments. It's essential to focus on the client's individual preferences and provide information to help her make an informed decision.

A. "Come with me to an area where we can talk without interruption." B. "Providers usually recommend relaxation exercises for clients who are as upset as you are." C. "An antianxiety pill works best for situations like this." D. "Most clients with anxiety issues benefit from lying down.".

Correct Answer is A

Explanation

The correct answer is choice A: "Come with me to an area where we can talk without interruption."

Choice A rationale:

The nurse's response of inviting the client to a quieter area for conversation demonstrates therapeutic communication. By offering a private space, the nurse acknowledges the client's distress and creates an environment conducive to open discussion. This response allows the client to express their feelings without the pressure of being observed or interrupted, fostering a sense of safety and trust.

Choice B rationale:

This response suggests recommending relaxation exercises, which might not be appropriate for a client in a heightened state of anxiety. While relaxation techniques can be helpful for managing anxiety, the client's current level of distress requires immediate attention and active engagement rather than advice on future interventions.

Choice C rationale:

Mentioning an antianxiety pill oversimplifies the situation and ignores the importance of therapeutic communication. Medication is not the primary intervention at this moment, and assuming that a pill would be the immediate solution could diminish the client's need to express their feelings and concerns.

Choice D rationale:

Suggesting that most clients with anxiety issues benefit from lying down is an inaccurate generalization. Different individuals have varying coping mechanisms, and the client's pacing and rambling indicate a need for active support and conversation, rather than a one-size-fits-all approach of lying down.

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A nurse is talking with a client diagnosed with schizophrenia. Suddenly the client states, "I'm frightened. Do you hear that? The voices are telling me to do terrible things." Which of the following responses by the nurse is appropriate?

Nursing Test Bank

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While in group therapy, a nurse is caring for a client who has cancer and is scheduled for immediate chemotherapy. The client tells the nurse that she wants to try nontraditional treatments first. Which of the following responses should the nurse make?

Correct Answer is B

Explanation

A nurse notices that a client who has moderate anxiety is pacing the corridor and rambling. As the nurse approaches, the client states, "I am at the end of my rope. I don't think I can take any more bad news." Which of the following responses should the nurse make?

Correct Answer is A

Explanation

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