A patient diagnosed with schizophrenia tells the nurse, "The CIA is monitoring us through the fluorescent lights in this room. Be careful what you say." Which response by the nurse would be most therapeutic?
"It sounds like you’re concerned about your privacy."
"The CIA is prohibited from operating in health care facilities."
"Let’s talk about something other than the CIA."
"You have lost touch with reality, which is a symptom of your illness."
The Correct Answer is A
Choice A reason: This response acknowledges the patient’s feelings without confirming or denying the delusion. It helps establish trust while maintaining therapeutic communication. By focusing on the patient’s underlying concern, it avoids reinforcing the delusional content.
Choice B reason: Stating that the CIA is prohibited in health care facilities engages with the delusion, which is non-therapeutic because it validates the false belief.
Choice C reason: Redirecting away from the delusion may seem dismissive and does not address the patient’s immediate feelings of fear or concern. This could cause the patient to feel unheard.
Choice D reason: Telling the patient they have “lost touch with reality” is confrontational and could increase defensiveness. It is not supportive or therapeutic in building rapport.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: The unconscious mind, according to psychoanalytic theory, is where repressed emotions, memories, and desires are stored. These hidden influences affect behavior and mental health without the individual’s conscious awareness.
Choice B reason: Active and current awareness of memories and thoughts describes the conscious mind, not the unconscious.
Choice C reason: Immediate awareness of sensory input and decision-making refers to the conscious and preconscious processes, not the unconscious.
Choice D reason: Voluntary motor control and coordination involve the motor cortex and cerebellum, unrelated to psychoanalytic concepts of the unconscious.
Correct Answer is ["B","D","E"]
Explanation
Choice A reason: Sharing personal loss shifts the focus away from the patient, which is not therapeutic. Self-disclosure in this way can hinder supportive communication.
Choice B reason: Suggesting a grief support group acknowledges the patient’s feelings while offering a constructive coping resource. It validates distress and provides support.
Choice C reason: Leaving the patient when they are emotionally vulnerable conveys abandonment instead of support, which is not therapeutic.
Choice D reason: Normalizing grief as a process that takes time offers reassurance without minimizing the client’s emotions. It helps the patient understand that healing is gradual.
Choice E reason: Encouraging the patient to share coping strategies promotes expression of feelings and helps the nurse assess adaptive versus maladaptive coping mechanisms.
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