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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
a. Hypoglycaemia can occur, but it is not as immediately life-threatening as cardiac dysrhythmia.
b. Endocrine imbalance and amenorrhea are significant but not usually immediately life-threatening.
c. Cold intolerance due to decreased metabolism is uncomfortable but not immediately life-threatening.
d. Cardiac dysrhythmias are a major health complication of anorexia nervosa due to electrolyte imbalances, particularly hypokalaemia, which can lead to cardiac arrest. This is a life-threatening condition that needs to be monitored closely.
Correct Answer is B
Explanation
a. decrease anxiety and ignore all the alternate personalities. Ignoring alternate personalities is not a therapeutic goal and could lead to further distress and fragmentation.
b. blend all the personalities into one. The primary goal of therapy for Dissociative Identity Disorder (DID) is often to integrate the separate identities into one cohesive identity, facilitating overall functioning and stability.
c. prevent social isolation: While preventing social isolation is important, it is not the primary therapeutic goal specific to DID.
d. forget the past trauma: The goal is not to forget the past trauma but to integrate and process traumatic memories in a healthy way, reducing the impact on the individual's functioning.
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