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?”
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D.
Choice A rationale:
Encouraging the family to take the client out of the facility for short periods of time may not be appropriate at this point. Abrupt changes in behavior, like sudden cheerfulness, might be a warning sign for potential suicide risk in individuals with depression. Allowing the client to leave the facility could increase the risk of harm.
Choice B rationale:
Rewarding the client for the change in behavior might inadvertently reinforce the idea that acting cheerful is desirable. This could hinder the client's progress and therapeutic understanding of their condition.
Choice C rationale:
Asking the client why her behavior has changed is a thoughtful and reasonable approach, but it might not address the potential underlying issues adequately. Depression can still be present, and sudden shifts in mood should be monitored closely.
Choice D rationale:
Monitoring the client's whereabouts at all times is the appropriate action. Sudden improvements in a depressed client's demeanor could indicate that they have made a decision to end their life. Monitoring ensures their safety and enables prompt intervention if needed.
Correct Answer is A
Explanation
Choice A rationale:
Twisting tongue movements are characteristic manifestations of tardive dyskinesia (TD). TD is a movement disorder associated with long-term use of antipsychotic medications like fluphenazine (Prolixin). These involuntary movements often involve the face and tongue and can be irreversible if not addressed promptly.
Choice B rationale:
Constant tapping of feet when sitting is not a typical manifestation of tardive dyskinesia. This type of movement might be related to restlessness or anxiety, but it is not specifically associated with the movement disorder caused by prolonged antipsychotic use.
Choice C rationale:
Shuffling gait can be associated with parkinsonism, which is another potential adverse effect of antipsychotic medications, including fluphenazine. However, for tardive dyskinesia, the characteristic movements are more often related to the face and mouth rather than the legs and gait.
Choice D rationale:
Sudden onset of high fever is not a manifestation of tardive dyskinesia. It could potentially be a sign of a different medical issue, such as an infection. However, it is not directly related to the movement disorder caused by long-term antipsychotic use.
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