A 16-year-old client diagnosed with schizophrenia disorder experiences command hallucinations to harm others. The client's parents ask a nurse, "Where do the voices come from?" Which is the appropriate nursing response?

"There is a chemical imbalance of the brain, which leads to altered perceptions."

"The hallucinations are caused by medication interactions."

"There is too little serotonin in the brain, causing delusions and hallucinations."

Abnormal hormonal changes have precipitated auditory hallucinations."

Answer and Explanation

The Correct Answer is A

a. "There is a chemical imbalance of the brain, which leads to altered perceptions." Schizophrenia is a complex mental health disorder with a strong biological component. While the exact cause is unknown, it's believed to involve abnormalities in brain chemistry and neurotransmitters. This is a general explanation that avoids going into too much detail but acknowledges the biological basis of hallucinations.
b. "The hallucinations are caused by medication interactions." Hallucinations are a core symptom of schizophrenia and not necessarily caused by medication interactions.
c. "There is too little serotonin in the brain, causing delusions and hallucinations." While serotonin might be involved in schizophrenia, it's not the only neurotransmitter implicated.
d. Abnormal hormonal changes have precipitated auditory hallucinations." Hormonal changes might influence mood, but they are not the primary cause of auditory hallucinations in schizophrenia.

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Correct Answer is A

Explanation

a. "The voices must sound scary, but the devil is not talking to you. This is part of your illness." Validating the experience ("The voices must sound scary") shows empathy and avoids dismissing the client's reality. Explaining it as part of the illness ("This is part of your illness") provides a non-judgmental explanation.
b. "The devil only talks to people who are receptive to his influence." Denying the voices can be dismissive and make the client feel isolated.
c. "You are not going to hell. You are a good person." While offering reassurance might seem comforting, it doesn't address the specific hallucination.
d. "Did you take your medicine this morning?" Medication is important, but the immediate priority is to address the hallucination and provide support.

A. "Can you order the specific events that led to your admission?" B. "Do you know why you are here?" C. "Are you feeling depressed or anxious?" D. "Yes, I see. Go on."

Correct Answer is D

Explanation

a. "Can you order the specific events that led to your admission?" This statement directs the client to provide specific information and is more focused than a general lead. It does not encourage a broad response.
b. "Do you know why you are here?" This question is somewhat open-ended but still directs the client's response toward understanding their admission.
c. "Are you feeling depressed or anxious?" This question is specific and closed-ended, prompting a choice between two options rather than encouraging the client to freely elaborate.
d. "Yes, I see. Go on." This is correct because it encourages the client to continue speaking without directing the topic, which is the essence of a general lead.

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A 16-year-old client diagnosed with schizophrenia disorder experiences command hallucinations to harm others. The client's parents ask a nurse, "Where do the voices come from?" Which is the appropriate nursing response?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client diagnosed with schizophrenia disorder states, "Can't you hear them? It's the devil. The devil is telling me I'm going to hell." Which is the most appropriate nursing response?

Correct Answer is A

Explanation

The nurse is interviewing a newly admitted client. Which of the following nursing statements is an example of offering a "general lead"?

Correct Answer is D

Explanation

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