A nurse on an inpatient mental health unit is caring for a client.

Exhibits

Select 4 findings the nurse should identify as positive manifestations of the clients diagnosis

Rationale for Correct Choices:

• Auditory hallucinations: The client reports hearing voices telling them to act (“I'm being told that it's better to end myself...”), which is a clear example of auditory hallucinations. These are a core positive symptom of schizophrenia and often command in nature.
• Echolalia: The client repeating the nurse’s words indicates echolalia, which reflects disorganized thought and speech. It is another classic positive symptom of schizophrenia and demonstrates impaired cognitive filtering.

Rationale for Incorrect Choices:

• Magical thinking: Magical thinking involves believing one’s thoughts can cause events in the physical world, such as thinking they can control others with their mind. This is not evident in the client’s current statements.
• Thought deletion: Thought deletion is the belief that external forces are removing thoughts from one’s mind. The client does not express this; instead, they report added stimuli (voices), not missing thoughts.
• Boundary impairment: Boundary impairment involves difficulty recognizing personal space or ownership, such as using others’ belongings inappropriately. This behavior has not been described in the current assessment.

Rationale:

A. Instruct the client to shower and change their clothes: The client should avoid bathing, showering, changing clothes, eating, or drinking before a forensic examination. These actions can destroy vital evidence needed for legal and medical purposes.

B. Ask the client for details about the assault: While the nurse should provide emotional support and allow the client to speak if they choose, probing for details can be retraumatizing. A trained forensic examiner should conduct this interview in a sensitive and structured manner.

C. Reassure the client that their injuries are not life threatening: While reassurance is important, making assumptions about the severity of injuries can invalidate the client’s emotional trauma. The nurse should focus on safety, stabilization, and support.

D. Limit the number of staff members providing care for the client: Reducing the number of caregivers helps minimize overstimulation, preserves privacy, and creates a sense of control and safety for the client. This trauma-informed approach is essential in early post-assault care.