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 B
Explanation
Choice A reason: Enhancing dopamine transmission is not the mechanism of antipsychotics; excessive dopamine is implicated in schizophrenia’s positive symptoms, so reducing—not enhancing—dopamine activity is key.
Choice B reason: Blocking both dopamine and serotonin receptors is characteristic of second-generation (atypical) antipsychotics. This dual action reduces extrapyramidal side effects while still targeting positive and negative symptoms.
Choice C reason: First-generation antipsychotics primarily block dopamine D2 receptors, which increases the risk for extrapyramidal side effects such as dystonia and parkinsonism.
Choice D reason: Selective serotonin receptor blockade is not the defining mechanism of second-generation antipsychotics. These medications act on both dopamine and serotonin systems.
Correct Answer is A
Explanation
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.
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