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

Explanation

Choice A rationale:

While wanting to go home to be with loved ones can be a sign of distress, it doesn't necessarily indicate an immediate risk of suicide. Many individuals express a desire to be with family when feeling down, and this statement alone is not a definitive indicator of suicide risk.

Choice B rationale:

Engaging in social activities like playing basketball with others is generally a positive sign, as it indicates some level of interaction and engagement. This choice is less likely to indicate an immediate suicide risk.

Choice C rationale:

The client demonstrating increased impulsive behaviors is a concerning sign. Rapid and impulsive actions can potentially lead to self-harm or dangerous situations. Increased impulsivity can indicate a lack of consideration for consequences, which may elevate the risk of suicidal behaviors.

Choice D rationale:

Identifying with problems expressed by other clients is not a specific indicator of suicide risk. While it may suggest empathy and shared experiences, it doesn't directly address the immediate risk factors related to the client's bipolar disorder.

A. "You should not feel guilty about your daughter's diagnosis. Schizophrenia is unpreventable.” B. "You said that you feel guilty about your daughter's diagnosis. Let's talk about what is causing you to feel this way.” C. "Your provider has explained the causes of schizophrenia. Why do you feel guilty about your daughter's diagnosis?” D. "I'm sure your daughter's diagnosis is very difficult to deal with, but everything will be all right once she receives the proper treatment.”

Correct Answer is B

Explanation

Choice A rationale:

Telling the parents that they should not feel guilty might invalidate their emotions and discourage open communication. It's essential to acknowledge their feelings and address them empathetically.

Choice B rationale:

This choice demonstrates therapeutic communication and empathy. It encourages the parents to express their feelings, and the nurse is offering to listen and explore the reasons behind their guilt.

Choice C rationale:

This statement seems confrontational and may discourage the parents from sharing their emotions openly. Asking why they feel guilty immediately might put them on the defensive.

Choice D rationale:

While this statement acknowledges the difficulty of the situation, it ends with a premature reassurance that may not be well-received. The parents need space to discuss their feelings before focusing on the future.

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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

Naxlex Comprehensive Predictor Exams

A nurse in an acute care mental health facility is assessing a client who has bipolar disorder. The nurse recognizes that which of the following findings indicates the client is at risk for suicide?

Correct Answer is C

Explanation

A nurse is caring for an adolescent client who has a new diagnosis of schizophrenia. The client's parents are tearful and express feelings of guilt. Which of the following is an appropriate statement by the nurse?

Correct Answer is B

Explanation

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