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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Use clear, calm statements and a confident physical stance:
This is the most appropriate choice. Clear and calm communication, along with a confident physical stance, can help to de-escalate the situation. It demonstrates assertiveness and can potentially prevent further escalation of violence.
B. Provide objective evidence that violence is unwarranted:
While providing objective evidence may be helpful in some situations, individuals with paranoid personality disorder may not respond well to attempts to prove that their perceptions are unwarranted. It could potentially escalate the situation.
C. Empathize with the client's paranoid perceptions:
While empathy is important in communication, empathizing with paranoid perceptions in a way that validates or reinforces them may not be the best approach. It could inadvertently validate the client's distorted thoughts and potentially escalate the situation.
D. Initially restrain the client to maintain safety:
Physical restraint should be a last resort and used only when the safety of the client or others is at immediate risk. Initial restraint can escalate aggression and may not be the most appropriate intervention in the early stages of a violent episode.
Correct Answer is D
Explanation
A. "The nurse shuffles through papers to determine the facility policy on length of group": This action suggests the nurse is seeking information to guide the group effectively, indicating an active leadership role rather than a laissez-faire style.
B. "The nurse mandates that all group members reveal an embarrassing personal situation": This action involves imposing a specific requirement on group members, which is not characteristic of a laissez-faire leadership style. It's more indicative of an authoritarian or directive approach.
C. "The nurse asks for a show of hands to determine group topic preference": Seeking input from group members is a participative leadership style rather than laissez-faire. Laissez-faire leadership involves minimal interference or direction from the leader.
D. "The nurse sits silently as the group members stray from the assigned topic": This action aligns with a laissez-faire leadership style, as the nurse is allowing the group to proceed without intervention or redirection, even if it means straying from the assigned topic.
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