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

Your child has a chemical imbalance of the brain, which leads to altered thoughts

Your child's hallucinations are caused by medication interactions

your child has too little serotonin in the brain causing delusions and hallucinations

your child's abnormal hormonal changes have precipitated auditory hallucinations

Answer and Explanation

The Correct Answer is A

A. Your child has a chemical imbalance of the brain, which leads to altered thoughts: This is the correct answer. It acknowledges the role of a chemical imbalance in the brain contributing to altered thoughts and hallucinations in the context of schizophrenia.

B. Your child's hallucinations are caused by medication interactions: This explanation is not likely in this context. While medications can have side effects, command hallucinations in schizophrenia are primarily related to the underlying disorder.

C. Your child has too little serotonin in the brain causing delusions and hallucinations: While serotonin is involved in mood regulation, attributing hallucinations solely to low serotonin levels oversimplifies the complex neurobiology of schizophrenia.

D. Your child's abnormal hormonal changes have precipitated auditory hallucinations: Hormonal changes are not considered a primary cause of auditory hallucinations in schizophrenia. The emphasis is on neurobiological and genetic factors influencing brain function.

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Correct Answer is A

Explanation

A. Use clear, calm statements and a confident physical stance:

This is the most appropriate choice. Clear and calm communication, along with a confident physical stance, can help to de-escalate the situation. It demonstrates assertiveness and can potentially prevent further escalation of violence.

B. Provide objective evidence that violence is unwarranted:

While providing objective evidence may be helpful in some situations, individuals with paranoid personality disorder may not respond well to attempts to prove that their perceptions are unwarranted. It could potentially escalate the situation.

C. Empathize with the client's paranoid perceptions:

While empathy is important in communication, empathizing with paranoid perceptions in a way that validates or reinforces them may not be the best approach. It could inadvertently validate the client's distorted thoughts and potentially escalate the situation.

D. Initially restrain the client to maintain safety:

Physical restraint should be a last resort and used only when the safety of the client or others is at immediate risk. Initial restraint can escalate aggression and may not be the most appropriate intervention in the early stages of a violent episode.

A. I'm the world's most perceptive attorney. B. The FBI is out to get me C. I can't stop my sexual urges. They have led me to numerous affairs. D. My wife is distraught about my overspending

Correct Answer is A

Explanation

A. "I'm the world's most perceptive attorney.": This statement reflects grandiosity, a common feature of grandiose delusions. The client is expressing an exaggerated belief in their own importance and abilities, indicating a distorted perception of reality.

B. "The FBI is out to get me": This statement suggests paranoid delusions, where the client believes they are being persecuted or conspired against. It does not specifically indicate grandiose delusions.

C. "I can't stop my sexual urges. They have led me to numerous affairs": This statement reflects impulsivity and hypersexuality, which are common features in manic episodes but do not specifically indicate grandiose delusions.

D. "My wife is distraught about my overspending": This statement reflects a consequence of manic behavior (overspending) but does not directly indicate grandiose delusions.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client diagnosed with paranoid personality disorder becomes violent on a unit. Which nursing intervention is most appropriate?

Correct Answer is A

Explanation

A nurse learns at report that a newly admitted client experiencing mania is demonstrating grandiose delusions. The nurse should recognize which client statement would provide supportive evidence of this symptom?

Correct Answer is A

Explanation

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