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 C
Explanation
Choice A reason: While silence may sometimes convey understanding, its primary therapeutic purpose in communication is to allow the patient time to think or reflect, not simply to indicate understanding.
Choice B reason: Prolonged silence may cause withdrawal in some patients, but this is not the guiding principle in therapeutic communication. The focus should be on the value of reflection.
Choice C reason: Silence provides the patient with opportunities for reflection and processing of thoughts and emotions. It encourages deeper expression and supports therapeutic dialogue.
Choice D reason: The nurse is not always responsible for breaking silence. Sometimes allowing the patient to break the silence themselves is more therapeutic and empowering.
Correct Answer is D
Explanation
Choice A reason: Schizotypal disorder is characterized by eccentric behaviors, odd beliefs, and perceptual distortions. While social difficulties are common, the primary feature is not a lack of interest in relationships but unusual thought patterns and behaviors.
Choice B reason: Paranoid personality disorder involves pervasive distrust and suspicion of others. Clients often avoid relationships due to fear of being exploited, not because of a lack of interest in intimacy.
Choice C reason: Antisocial personality disorder is defined by disregard for others’ rights, impulsivity, and rule-breaking behaviors, not by withdrawal from sexual or social relationships.
Choice D reason: Schizoid disorder is marked by detachment from social relationships and a limited range of emotional expression, including little to no interest in sexual activity or partnerships, making this the best match.
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