A client diagnosed with schizophrenia disorder states, "Can't you hear them? It's the devil. The devil is telling me I'm going to hell." Which is the most appropriate nursing response?

"The voices must sound scary, but the devil is not talking to you. This is part of your illness."

"The devil only talks to people who are receptive to his influence."

"You are not going to hell. You are a good person."

"Did you take your medicine this morning?"

Answer and Explanation

The Correct Answer is A

a. "The voices must sound scary, but the devil is not talking to you. This is part of your illness." Validating the experience ("The voices must sound scary") shows empathy and avoids dismissing the client's reality. Explaining it as part of the illness ("This is part of your illness") provides a non-judgmental explanation.
b. "The devil only talks to people who are receptive to his influence." Denying the voices can be dismissive and make the client feel isolated.
c. "You are not going to hell. You are a good person." While offering reassurance might seem comforting, it doesn't address the specific hallucination.
d. "Did you take your medicine this morning?" Medication is important, but the immediate priority is to address the hallucination and provide support.

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Correct Answer is C

Explanation

a. Can stop taking this medication abruptly without serious complications: Abruptly stopping diazepam, especially after long-term use, can lead to withdrawal symptoms like anxiety, seizures, and insomnia.
b. Will need scheduled blood work in order to monitor for toxic levels of this drug: While monitoring might be necessary in some cases, it's not typical for everyone on diazepam.
c. Will not drink alcohol while taking this medication. (Correct) Diazepam is a central nervous system depressant. Alcohol has similar effects, and combining them can significantly increase the risk of drowsiness, impaired coordination, and respiratory depression. Understanding this interaction is crucial for safe medication use.
d. Will have to take this medication for the rest of my life: The duration of diazepam therapy depends on the individual and the condition being treated.

A. "I can make that promise to you based on nurse-client privilege." B. "Those kinds of thoughts will make your hospitalization longer." C. "I cannot promise that. Confidentiality does not include plans to hurt others." D. "You should share this thought with your psychiatrist."

Correct Answer is C

Explanation

a. "I can make that promise to you based on nurse-client privilege." Nurse-client confidentiality is important, but it doesn't apply to threats of violence. The nurse has a duty to protect the client and others.
b. "Those kinds of thoughts will make your hospitalization longer." While true, this response doesn't directly address the safety concern and might be perceived as judgmental.
c. "I cannot promise that. Confidentiality does not include plans to hurt others." This is a clear and honest statement. It explains the limitations of confidentiality and prioritizes safety.
d. "You should share this thought with your psychiatrist." While encouraging the client to talk to a psychiatrist is a good suggestion, it doesn't directly address the confidentiality issue or the immediate threat.

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A client diagnosed with schizophrenia disorder states, "Can't you hear them? It's the devil. The devil is telling me I'm going to hell." Which is the most appropriate nursing response?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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