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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

a. experience no loss of contact with reality. The key difference is reality testing. Clients with neurosis (anxiety disorders, OCD) generally maintain contact with reality, even though their thoughts or behaviours might be distressing. Clients with psychosis (schizophrenia) experience a break with reality, such as hallucinations or delusions.
b. Never have mood or personality changes. Not true. Mood and personality changes can occur in both neurosis and psychosis.
c. Have conflict but only use adaptive defence mechanisms to cope. Défense mechanisms are used by everyone to cope with anxiety, but in neurosis, they might be less healthy or maladaptive.
d. Are always aware that their behaviours are maladaptive. Not necessarily. Clients with neurosis might have limited insight into how their behaviours affect themselves or others.

A. 1030-1130 B. 1130-1230 C. 1000 D. 0800-0830

Correct Answer is A

Explanation

a. 1030-1130: Insulin aspart is a rapid-acting insulin that typically peaks in 1-2 hours. Hypoglycemia is most likely to occur during the peak action time.
b. 1130-1230: This is beyond the typical peak action time for insulin aspart, making hypoglycemia less likely during this interval.
c. 1000: This falls within the typical peak action time of 1-2 hours for insulin aspart, making hypoglycemia possible but the interval is slightly too narrow to capture the full peak effect.
d. 0800-0830: Insulin aspart begins to act within 10-20 minutes, but hypoglycemia typically does not occur this soon after administration unless there is an issue with meal timing or dosage.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

The nurse's approach to a client with neurotic vs. psychotic behavior is different mainly because clients with neurotic behavior.

Correct Answer is A

Explanation

A client takes the morning dose of 10 units of insulin aspart at 0800. At what time interval would the nurse most likely see hypoglycemia?

Correct Answer is A

Explanation

A client is diagnosed with Trichotillomania. The client has relieved the anxiety over the years by doing what type of behavior?

The nurse is assessing the status of a post-operative client in the PACU. The nurse should be most concerned with which assessment finding?

The nurse is caring for a client who has anger management issues and starts to explore a career as a professional wrestler. This is an example of which defense mechanism?

A 13-year-old is about to take a math test. A nursing assessment reveals mild anxiety. The nurse explains that this level of anxiety.

The nurse is interviewing a newly admitted client. Which of the following nursing statements is an example of offering a "general lead"?

Which of the following would be the best nursing action for a client who is having a panic attack?

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 nurse is assessing a client diagnosed with schizophrenia, who has been prescribed Haloperidol for the past year. On assessment, the nurse notices that the client is demonstrating bizarre facial and tongue movements. What is the priority nursing intervention?