A client who has schizophrenia is talking to the nurse and states, "Do you hear that? I am scared. The voices are telling me to do horrible things which of the following responses by the nurse is appropriate?
"You need to understand there are no voices"
What are the voices telling you to do?
What do you think is causing you to heal the voices?
"You need to tell the forces to leave you alone.
The Correct Answer is B
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
a. time of day. The time of day is not a significant factor in determining whether a situation will be perceived as a crisis.
b. client's perception of the event. This is correct because an individual's perception of an event greatly influences whether it is experienced as a crisis.
c. availability of adequate coping mechanisms. This is correct because having effective coping mechanisms can mitigate the impact of a stressful situation and prevent it from becoming a crisis.
d. availability of supports. This is correct because having a supportive network can help individuals manage stress and reduce the likelihood of a crisis.
e. location of a treatment centre. While access to treatment is important, the immediate experience of a crisis is more influenced by perception, coping mechanisms, and support systems than the location of a treatment centre.
Correct Answer is C
Explanation
a. Is pathological and warrants postponing the test: Not necessarily true. Mild anxiety is a normal human response to stressful situations. Postponing the test might reinforce avoidance behaviors.
b. May be transferred to classmates and result in test anxiety: While anxiety can be contagious in some situations, the nurse should focus on calming techniques for the individual experiencing it, not assuming it will spread.
c. is conducive to concentration and problem solving (Correct): Mild anxiety, also known as arousal, can heighten focus and alertness. This can be beneficial for tasks that require concentration, like tests. In some cases, it can improve cognitive function
d. Will interfere with cognitive ability: Extreme anxiety can be debilitating, but mild anxiety can actually enhance focus and performance in some situations.
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