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 B

Explanation

Choice A Reason:
Laughing inappropriately, such as when watching a sad movie, can be a symptom of schizophrenia, but it is not specific to the catatonic subtype. Inappropriate affect may occur in schizophrenia but does not solely characterize catatonic behavior.

Choice B Reason:
Catatonic schizophrenia is marked by periods of immobility or stupor. A client who maintains an immobilized state for several hours is displaying a classic sign of catatonia. During these periods, the client may be mute, rigid, and resistant to movement, which are key features of this condition.

Choice C Reason:
Refusing to eat certain types of food is not specifically indicative of catatonic schizophrenia. While individuals with schizophrenia may have unusual preferences or fears related to food, this behavior could be related to a variety of factors and is not a definitive sign of catatonia.

Choice D Reason:
Using a rhyming form of speech, known as clang associations, can be seen in schizophrenia but is more characteristic of disorganized thinking associated with the disorder rather than catatonia. Catatonia involves motoric symptoms rather than speech patterns.

A. Talk to the client and identify the specific limits that are required of the client's behavior. B. Discuss the problem in a community meeting with the other clients on the unit present. C. Escort the client to her room each time the nurse observes the client socializing with other clients. D. Tell the other clients to ignore the client's lies.

Correct Answer is A

Explanation

Choice A reason:
Talking directly to the client and setting clear boundaries is a therapeutic approach. It respects the client's autonomy while also addressing the behavior that is affecting the therapeutic environment. By identifying specific limits, the nurse helps the client understand the consequences of their actions and the importance of maintaining a respectful and honest communication with others.

Choice B reason:
Discussing the problem in a community meeting could be helpful, but it should not be the initial action. This approach might inadvertently shame or embarrass the client in front of peers, which could exacerbate the situation. It's important to address the behavior privately before involving the larger group.

Choice C reason:
Escorting the client to their room each time they socialize could be seen as punitive and may not address the underlying reasons for the lying behavior. It could also isolate the client from social interactions that are an essential part of the healing process.

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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

The nurse is caring for a newly admitted client diagnosed with catatonic schizophrenia. Which of the following behaviors should the nurse document to be consistent with catatonic schizophrenia? The client:

Correct Answer is B

Explanation

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?

Correct Answer is A

Explanation

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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?

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