A charge nurse overhears another nurse talking with a client who has schizophrenia. Suddenly the client yells, "I am the devil! I am God! Open the gate for me!" Which of the following replies by the nurse requires intervention?
"There is no gate for me to open."
"I don't understand. Can you tell me what that means?"
"Are you saying that you are both good and bad?"
"It sounds frightening to feel like both God and the devil at the same time."
The Correct Answer is A
Choice A Reason:
This response may invalidate the client's experience and can be perceived as dismissive of the client's delusional thoughts. It does not acknowledge the client's current reality or provide any therapeutic communication. An intervention is required to guide the nurse in offering a more empathetic and validating response.
Choice B Reason:
Asking the client to clarify what they mean encourages communication and shows a willingness to understand the client's perspective. It is a therapeutic approach that can help the nurse gain insight into the client's thoughts and provide appropriate support.
Choice C Reason:
This response could potentially validate the client's delusional thinking by engaging in the content of the delusion. It might lead to further discussion about the delusion rather than redirecting the client to reality, which could be counterproductive.
Choice D Reason:
Expressing empathy by acknowledging that the client's feelings must be frightening is a therapeutic response. It validates the client's emotions without confirming the delusional content and can help the client feel understood and supported.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D"]
Explanation
Choice A Reason:
Blunted affect refers to a significant reduction in the intensity of emotional expression. In the context of schizophrenia, a person with blunted affect may show less facial expression, have diminished expressive gestures, and a monotone voice. This symptom reflects a decrease in the expression of emotions, which is characteristic of the negative symptoms of schizophrenia.
Choice B Reason:
Delusions are a type of positive symptom of schizophrenia, not a negative one. They are false beliefs that are not based in reality, such as thinking one has superpowers or is being persecuted. Delusions represent an excess or distortion of normal functions.
Choice C Reason:
Poor judgment is not typically classified as a negative symptom of schizophrenia. It can be a consequence of cognitive impairments or positive symptoms like delusions but is not a negative symptom itself.
Choice D Reason:
Anhedonia is the inability to feel pleasure and is a core negative symptom of schizophrenia. Individuals with anhedonia may not enjoy activities that they used to find pleasurable, which can significantly impact their quality of life.
Choice E Reason:
Hallucinations, like delusions, are considered positive symptoms of schizophrenia. They involve experiencing sensations that are not present, such as hearing voices or seeing things that others do not see.
Correct Answer is D
Explanation
Choice A Reason:
Providing sympathy can be comforting, but it may not always be conducive to establishing a therapeutic relationship. Sympathy involves feeling pity for someone else's misfortune, which can sometimes create a power imbalance or imply that the nurse sees the client as unable to cope. In contrast, empathy, which is understanding and sharing the feelings of another, is more aligned with therapeutic communication principles.
Choice B Reason:
Focusing on the words of the clients is important, but it is only one aspect of communication. Therapeutic relationships are built on understanding the full context of communication, including non-verbal cues and emotional undertones. Active listening involves not just hearing words, but also interpreting the message being conveyed and responding appropriately.
Choice C Reason:
Controlling the pace of establishing nurse-client relationships might be necessary in certain situations, but it should not be the primary action. Each client is unique, and the development of a therapeutic relationship will vary depending on individual needs and circumstances. The nurse should be flexible and patient, allowing the relationship to develop naturally.
Choice D Reason:
Demonstrating genuineness when communicating is fundamental to building trust and rapport, which are essential components of a therapeutic relationship. Genuineness involves being open, honest, and sincere. When nurses are genuine, clients are more likely to feel respected and understood, leading to a stronger therapeutic alliance.
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