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. "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.

A. Clinically significant distress in occupational functioning. B. Sudden unexpected travel or confused wandering. C. An inability to recall their parent's contact information. D. Occasional periods of forgetfulness

Correct Answer is B

Explanation

a. Clinically significant distress in occupational functioning. While distress in occupational functioning may occur, it is not specific to dissociative fugue and is more broadly associated with various mental health disorders.
b. Sudden unexpected travel or confused wandering. This choice is correct because dissociative fugue is characterized by sudden, unexpected travel away from one's home or usual place of work, with an inability to recall some or all of one's past.
c. An inability to recall their parent's contact information. While memory loss is part of dissociative fugue, the focus is on broader, more significant amnesia than just inability to recall specific information like contact details.
d. Occasional periods of forgetfulness. This does not capture the severity or the specific nature of the amnesia involved in dissociative fugue.

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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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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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