A client diagnosed with schizophrenia states, Can't you hear him? Its the devil. He's telling me I'm going to hell. Which is the most appropriate nursing reply?

Did you take your medicine this morning?

i'm sure the voices sound scary, I don't hear any voices speaking

The devil only talks to people who are receptive to his influence

You are not going to hell. You are a good person

Answer and Explanation

The Correct Answer is B

A. "Did you take your medicine this morning?": While medication adherence is important, this response does not directly address the client's distress or validate their experience. It may come across as dismissive.

B. "I'm sure the voices sound scary, I don't hear any voices speaking.": This response acknowledges the client's experience without confirming or denying the presence of the voices. It expresses empathy and provides reassurance, fostering a therapeutic relationship.

C. "The devil only talks to people who are receptive to his influence": This response introduces a belief system that may not align with the client's reality and could be perceived as judgmental. It's important to avoid imposing personal beliefs on clients experiencing hallucinations.

D. "You are not going to hell. You are a good person": While expressing support and reassurance is positive, making definitive statements about the client's fate or goodness may not be helpful. It's more effective to acknowledge the distress without making absolute affirmations.

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Correct Answer is B

Explanation

A. Altered thought process related to hallucinations: While altered thought processes are common in manic episodes, hallucinations are not typically associated with mania in Bipolar I disorder. Hallucinations are more commonly seen in psychotic disorders.

B. Risk for violence related to poor impulse control and judgment: This is the correct priority diagnosis. During a manic episode, individuals may have impaired impulse control and poor judgment, increasing the risk of impulsive and potentially violent behaviors. Ensuring the safety of the client and others is the priority.

C. Altered thought process related to poor judgment: While altered thought processes and poor judgment are characteristic of mania, the specific concern in this scenario is the potential for violence. The risk for violence takes precedence as a priority nursing diagnosis.

D. Social isolation related to mania: Social isolation may be a concern, but the immediate priority is addressing the risk for violence, as it poses a more significant threat to the client and others during a manic episode.

A. Mental health and mental illness are the same concepts B. "Mental health can present at any age, whereas mental illness can only present after age 20 C. Mental illness is when there is a disruption in a person’s ability to complete activities of daily living, whereas mental health is when the person can cope with daily stressors D. Mental illness is a condition caused by poor mental health

Correct Answer is C

Explanation

A. Incorrect. Mental health and mental illness are not the same concepts. Mental health refers to a person's emotional, psychological, and social well-being, while mental illness refers to specific mental health conditions that significantly affect a person's thoughts, emotions, and behaviors.

B. Incorrect. Mental health and mental illness can both present at any age. Mental health is a broader concept that encompasses overall well-being, while mental illnesses can manifest at various stages of life.

C. Correct. This statement accurately distinguishes between mental health and mental illness. Mental health involves the ability to cope with daily stressors, while mental illness is characterized by disruptions in activities of daily living due to specific mental health conditions.

D. Incorrect. This statement confuses the relationship between mental health and mental illness. Mental health is a broader concept that contributes to overall well-being, while mental illness is a specific condition that may arise due to various factors, including poor mental health.

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A client diagnosed with schizophrenia states, Can't you hear him? Its the devil. He's telling me I'm going to hell. Which is the most appropriate nursing reply?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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