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
Explanation
Choice A Reason:
This statement is an example of assertive communication because it acknowledges the client's feelings while also standing firm on the nurse's actions. Assertive communication is characterized by being direct, clear, concise, honest, confident, and respectful¹. It involves expressing thoughts and feelings in a considerate way that respects others, aiming to foster and maintain healthy relationships, rectify conflicts, and prevent resentment due to unexpressed needs.
Choice B Reason:
Telling a client to calm down can be perceived as dismissive and may not be considered assertive communication. It does not acknowledge the client's feelings and can come across as commanding or condescending, which may escalate the situation rather than resolve it.
Choice C Reason:
While this statement does convey the consequences of the client's actions, it lacks the empathy component that is crucial in assertive communication. It is important to balance directness with understanding when addressing sensitive issues.
Choice D Reason:
Asking why the client chose to behave negatively could be seen as confrontational and may put the client on the defensive. Assertive communication aims to avoid power games and foster clear outcomes, which is best achieved through statements that do not provoke or blame.
Correct Answer is C
Explanation
Choice A Reason:
While suggesting the client discuss their concerns with their physician is a valid response, it may not provide the immediate emotional support the client is seeking. It's important for the nurse to address the client's current anxiety and provide reassurance before referring them to their physician.
Choice B Reason:
This response dismisses the client's fears and may come across as insensitive. It's crucial to acknowledge the client's emotions and provide a supportive environment where they feel heard and understood.
Choice C Reason:
Encouraging the client to express their fears allows the nurse to provide emotional support and helps in understanding the client's perspective. This approach fosters a therapeutic relationship and can help alleviate the client's anxiety.
Choice D Reason:
While recommending lifestyle changes is beneficial for overall health, this response does not address the client's immediate emotional needs. The nurse should first provide support for the client's expressed fears before discussing lifestyle modifications.
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