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?"
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
a. Recovery from anorexia nervosa is a marathon, not a sprint. Setting small, achievable goals like understanding the importance of nutrition is crucial for initial progress.
b. Aiming for immediate, perfect dietary adherence is unrealistic and can be discouraging. Building healthy eating habits takes time and support.
c. Unrealistic weight gain goals can be demotivating and potentially harmful. Weight gain should be gradual and monitored by a healthcare professional.
d. A sudden high-calorie diet can be overwhelming for someone with a restricted eating pattern and could lead to gastrointestinal distress.
Correct Answer is C
Explanation
a. His wife has minimal family support: While limited family support might affect the caregiver’s burden, it does not directly imply immediate safety concerns for the client.
b. His wife works from home in telecommunication: Working from home can be beneficial as she is physically present to assist the client.
c. The client smokes one pack of cigarettes per day. Smoking increases the risk of cardiovascular events and other health complications, which can exacerbate symptoms of vascular NCD and pose safety risks.
d. The client has worked nightshift his entire life. While working night shifts might affect his sleep patterns, it does not pose an immediate safety concern compared to the risk associated with smoking.
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