A nursing student is preparing to care for a client diagnosed with schizophrenia. When interacting with the client, the student notices that the client is highly suspicious and guarded, stating, "They're out to get me." The student identifies this as what?
Paranoia.
Stilted language.
Pressured speech.
Autistic thinking.
The Correct Answer is A
Choice A reason: This is the correct choice. The client's belief that "They're out to get me" is indicative of paranoia, a common symptom in schizophrenia.
Choice B reason: This choice is incorrect. Stilted language refers to an unnatural, formal way of speaking, not suspicion or guardedness.
Choice C reason: This choice is incorrect. Pressured speech is rapid and urgent speech, which is not described in the scenario.
Choice D reason: This choice is incorrect. Autistic thinking is associated with autism, not schizophrenia, and does not involve paranoia.
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Correct Answer is D
Explanation
Choice A reason: This choice is incorrect. While anxiety can be a normal response to stress, the context implies that the client is experiencing more than a typical reaction.
Choice B reason: This choice is incorrect. Anxiety is not necessarily an abnormal response; it can occur in normal situations but becomes problematic when excessive.
Choice C reason: This choice is incorrect. While anxiety does have physiological components, the question seems to be asking about the experiential nature of anxiety.
Choice D reason: This is the correct choice. Anxiety is indeed a sense of psychological distress that can be triggered by stress but is characterized by excessive worry, fear, or apprehension.
Correct Answer is C
Explanation
Choice A reason: This choice is incorrect. Asking questions that can be answered with one-word responses does not facilitate a deep therapeutic relationship.
Choice B reason: While involving the family can be beneficial, it is not a direct strategy for the nurse-client relationship.
Choice C reason: This is the correct choice. Active listening and summarizing are key components of building a therapeutic relationship, as they demonstrate understanding and validation of the client's feelings and thoughts.
Choice D reason: It is important to ask about suicidal behaviors or thoughts when there are indications of such risks; avoiding these questions can be detrimental to client care.
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