A client diagnosed with schizophrenia disorder states, "My psychiatrist is out to get me. I'm sad that the voice is telling me to stop the psychiatrist." What symptom is the client exhibiting, and what is the nurse's legal responsibility related to this symptom?
Altered thought processes; call an emergency treatment team meeting.
Command hallucinations; warn the psychiatrist.
Persecutory delusions; orient the client to reality.
Magical thinking; administer an antipsychotic medication.
The Correct Answer is B
a. Altered thought processes; call an emergency treatment team meeting. While altered thought processes are present, the urgent concern is the command hallucination directing the client to harm the psychiatrist. An emergency treatment team meeting may not provide the immediate intervention required.
b. Command hallucinations; warn the psychiatrist. This is correct because the client is experiencing command hallucinations that pose a direct threat to the psychiatrist. The nurse has a duty to warn the potential victim and ensure the safety of both the client and others.
c. Persecutory delusions; orient the client to reality. Persecutory delusions are present, but the immediate danger from the command hallucinations takes precedence. Orienting the client to reality does not address the urgent safety issue.
d. Magical thinking; administer an antipsychotic medication. Magical thinking is not the correct symptom here. Administering medication is part of treatment but does not address the immediate safety concern.
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Related Questions
Correct Answer is D
Explanation
a. Food is rapidly ingested without proper chewing: While this might happen in bulimia nervosa, it does not explain dental erosion.
b. Purging causes the depletion of dietary calcium: Calcium depletion could affect bones and teeth but is not the primary reason for the dental erosion seen in bulimia nervosa.
c. Poor dental and oral hygiene lead to dental caries: While poor hygiene can contribute to dental issues, the primary cause of dental deterioration in bulimia is the acid from vomiting.
d. Emesis from purging corrodes the tooth enamel. Frequent vomiting in bulimia nervosa exposes teeth to stomach acid, which erodes the enamel and leads to dental deterioration.
Correct Answer is B
Explanation
a. "You need to understand there are no voices": Denying the client's experience can be invalidating and unhelpful.
b. What are the voices telling you to do? (Correct)A key principle in responding to someone experiencing auditory hallucinations is to validate their experience and ask open-ended questions. This helps the client feel heard and allows the nurse to assess the severity of the situation and potential safety risks.
c. What do you think is causing you to hear the voices? While exploring the cause of hallucinations can be part of therapy, in the immediate situation, focusing on what the voices are saying and assessing safety is more important.
d. "You need to tell the forces to leave you alone": This is confrontational and doesn't acknowledge the client's fear. It might also reinforce the belief in the voices having power.
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