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. While taking slow, deep breaths can help with relaxation and possibly with managing anxiety or panic attacks, it is not directly addressing the combined side effects of these medications.
b. Wearing sunscreen and avoiding midday sun exposure is important to prevent photosensitivity reactions caused by some antipsychotics, but it is not related to the combined effects of antipsychotics and beta-blockers.
c. Watching diet and engaging in physical activity are generally good health practices but do not specifically address the combined side effects of these medications.
d. "Rise slowly when you change position from lying to sitting or sitting to standing." Both antipsychotics and beta-adrenergic blocking agents can cause orthostatic hypotension, which is a sudden drop in blood pressure when changing positions. This can lead to dizziness, lightheadedness, or even fainting. Advising the client to rise slowly helps to prevent these effects and ensures the client’s safety
Correct Answer is D
Explanation
a. Focused conversations on various foods: While a healthy relationship with food is a treatment goal, focusing excessively on food during therapy sessions might indicate continued preoccupation, not necessarily a positive change.
b. Is able to binge eat without purging: This might seem positive on the surface, but it doesn't address the underlying problem of binge eating. The goal is to develop healthy eating habits and reduce both bingeing and purging behaviors.
c. Gained ten pounds in one week: Rapid weight gain is unlikely to be a healthy or sustainable outcome in bulimia nervosa treatment. It's important to focus on healthy weight management alongside addressing the core eating disorder behaviors.
d. Demonstrated healthy coping mechanisms that decreased anxiety (Correct): Bulimia nervosa involves recurrent episodes of binge eating followed by purging behaviors. Recovery involves developing healthy coping mechanisms to manage anxiety and reduce the urge to binge or purge. This is a key indicator of progress.
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