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 ["C","D"]

Explanation

The correct answer is choice c. Believes that others are deceiving him, and choice d.Continuously holds onto grudges

Choice A rationale:

Perceiving oneself as inferior to others is more characteristic of avoidant personality disorder, where individuals often avoid social situations due to feelings of inadequacy and fear of rejection.

Choice B rationale:

Desiring to be the center of attention is a trait often seen in histrionic personality disorder, where individuals crave attention and may use dramatic behavior to achieve it.

Choice C rationale:

Individuals with paranoid personality disorder tend to have a pervasive and unjustified mistrust of others. They often believe that others are deceiving, exploiting, or harming them, even in the absence of evidence to support these beliefs. This mistrust is a central characteristic of this disorder.

Choice D rationale:

Continuously holding onto grudges is another hallmark feature of paranoid personality disorder. These individuals are prone to bearing grudges and being unforgiving, as they are hypersensitive to perceived slights or insults.

Choice E rationale:

Exhibiting a grandiose sense of self-importance is more characteristic of narcissistic personality disorder, where individuals have an inflated sense of their own importance and often lack empathy for others.

A. Lithium (Eskalith). B. Donepezil (Aricept). C. Valproate (Depakote). D. Carbamazepine (Tegretol). E. Paroxetine (Paxil).

Correct Answer is ["A","C","D"]

Explanation

Choice A rationale:

Lithium is a mood stabilizer commonly used to treat bipolar disorder. It helps to regulate mood swings, prevent manic episodes, and reduce the risk of depressive episodes.

Choice B rationale:

Donepezil is not used to treat bipolar disorder. It is an acetylcholinesterase inhibitor primarily used to treat symptoms of Alzheimer's disease.

Choice C rationale:

Valproate (Depakote) is another mood stabilizer used in the treatment of bipolar disorder. It can help manage both manic and depressive episodes, as well as prevent future mood swings.

Choice D rationale:

Carbamazepine (Tegretol) is an anticonvulsant medication that also has mood-stabilizing properties. It is often prescribed for individuals with bipolar disorder, especially those who do not respond well to lithium.

Choice E rationale:

Paroxetine (Paxil) is a selective serotonin reuptake inhibitor (SSRI) commonly used to treat depression and anxiety disorders. It is not a primary medication choice for bipolar disorder.

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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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