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."

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A reason:
Occupational therapists are trained to help individuals develop or regain the skills needed for daily living and working. They are particularly adept at assisting clients with work-related skills, making them an ideal choice for this client's plan of care.

Choice B reason:
While psychiatrists are essential for diagnosing and treating mental health conditions, their role is less focused on teaching work-related skills and more on managing the client's psychiatric treatment.

Choice C reason:
Social workers provide valuable support in connecting clients with community resources and supporting their psychosocial needs. However, they do not typically specialize in teaching work-related skills.

Choice D reason:
Psychologists may work with clients to address cognitive or emotional barriers to employment, but they do not typically provide hands-on training in work-related skills as occupational therapists do.

A. Directly tell the client that the delusions are not real. B. Use frequent touch to provide client support. C. Place the client in seclusion if visual hallucinations are present. D. Limit the number of questions asked during assessments.

Correct Answer is D

Explanation

Choice A Reason:
Directly telling a client that their delusions are not real is not typically recommended. This approach can be confrontational and may lead to increased anxiety or agitation in the client. It's important to maintain a therapeutic relationship by validating the client's feelings and working within their current reality, rather than directly challenging their perceptions.

Choice B Reason:
Using frequent touch to provide support may not be appropriate for all clients, especially those with schizophrenia who may have altered perceptions of reality. Some individuals may find touch comforting, while others may perceive it as threatening or invasive. It's crucial to assess each client's comfort level with physical contact and proceed accordingly.

Choice C Reason:
Placing a client in seclusion can be a traumatic experience and is generally considered a last resort when other interventions have failed and the client is a danger to themselves or others. Seclusion should not be used solely because a client is experiencing visual hallucinations.

Choice D Reason:
Limiting the number of questions during assessments can help reduce the potential for overwhelming the client. Clients with schizophrenia may have difficulty processing too much information at once, and a barrage of questions can be stressful. Simplifying communication and allowing the client to focus on one question at a time can be more effective.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on a mental health unit is caring for a client whose plan of care includes learning work-related skills. Which of the following members of the interprofessional team is appropriate for this client?

Correct Answer is A

Explanation

A nurse is developing a care plan for a newly admitted client who has schizophrenia and experiences frequent hallucinations and paranoid delusions. Which of the following actions should the nurse plan to take?

Correct Answer is D

Explanation

A nurse in a psychiatric unit is admitting a client who attacked a neighbor. The nurse should know that the client can be kept in the hospital after the 72-hour hold is over for which of the following conditions?

A nurse is leading a group therapy session for clients who are newly diagnosed with cancer. Which of the following statements should the nurse make?

The nurse is caring for a client diagnosed with schizophrenia. Which of the following should the nurse identify as findings consistent with schizophrenia? (Select all that apply.)

The nurse is caring for a client in an acute mental health unit. The client states, “I believe my food is poisoned.” Which of the following should be an appropriate action by the nurse?

A nursing instructor teaches students about the purpose of using the nursing process in the care of psychiatric clients. Which of the following statements by a student indicates that learning has occurred?

A nurse is caring for a hospitalized client who tells lies about other clients. The other clients on the unit frequently complain to the nursing staff about the client's disruptive behaviors. Which of the following initial actions should the nurse take?

A nurse is assessing a client who is receiving treatment with multiple antipsychotic medications and who suddenly became ill. The findings include blood pressure changes, fever, and diaphoresis. The nurse should recognize that which of the following adverse effects may be occurring?

A nurse is teaching about physiological responses to stress with a group of clients. The nurse should identify that which of the following changes reflect long-term physiological responses to stress? (Select all that apply)