A client with schizophrenia approaches the nurse with a look of distress and anguish on his face. He says, “Can’t you hear him? It’s the devil. He’s telling me I’m going to hell.” Which is the most appropriate response by the nurse?

“There is no such thing as the devil. It’s all in your mind.”

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

“Did you take your medicine this morning?”

“The voices sound distressing, but I don’t hear them.”

Answer and Explanation

The Correct Answer is D

Choice A Reason:

“There is no such thing as the devil. It’s all in your mind.”

This response dismisses the client’s experience and can make them feel invalidated. Telling the client that their experience is “all in your mind” does not acknowledge their distress and can increase their feelings of isolation and mistrust. It is important to validate the client’s feelings while gently orienting them to reality.

Choice B Reason:

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

While this response is supportive, it does not address the client’s immediate distress about hearing voices. It is important to acknowledge the client’s experience of hearing voices and provide reassurance in a way that helps them feel understood and supported. Simply telling them they are a good person may not alleviate their anxiety about the voices.

Choice C Reason:

“Did you take your medicine this morning?”

Asking about medication adherence is important, but it is not the most appropriate immediate response to the client’s distress. This question can come across as dismissive and may not provide the immediate comfort and validation the client needs. It is better to first acknowledge the client’s experience and then address medication adherence later.

Choice D Reason:

“The voices sound distressing, but I don’t hear them.”

This is the correct response. It acknowledges the client’s distress and validates their experience without reinforcing the delusion. By stating that the nurse does not hear the voices, it gently orients the client to reality while showing empathy and understanding. This approach helps build trust and provides comfort to the client.

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Correct Answer is A

Explanation

The correct answer is a.

Choice A Reason:

The statement “Biofeedback” is correct. Biofeedback is a technique that uses electronic monitoring devices to help individuals gain control over involuntary bodily functions such as heart rate, muscle tension, and blood pressure. During biofeedback sessions, sensors are attached to the body to measure physiological functions, and the feedback from these sensors helps clients learn to control their physical responses to stress. This method is particularly effective for managing conditions like chronic pain, anxiety, and hypertension.

Choice B Reason:

The statement “Acupuncture” is incorrect. Acupuncture is a traditional Chinese medicine practice that involves inserting thin needles into specific points on the body to balance the flow of energy or qi. While acupuncture can help manage stress and pain, it does not use electronic monitoring devices to provide feedback on physiological functions5. Instead, it relies on the practitioner’s skill and knowledge of acupuncture points and meridians.

Choice C Reason:

The statement “Reiki” is incorrect. Reiki is a form of energy healing that involves the practitioner placing their hands lightly on or just above the client’s body to channel healing energy. Reiki aims to promote relaxation, reduce stress, and support the body’s natural healing processes. However, it does not involve the use of electronic monitoring devices to provide feedback on physiological functions.

Choice D Reason:

The statement “Autogenic training” is incorrect. Autogenic training is a relaxation technique that involves self-suggestion and visualization to induce a state of relaxation and reduce stress. It focuses on creating sensations of warmth and heaviness in different parts of the body through repeated phrases and mental imagery. While effective for stress management, it does not use electronic monitoring devices to provide feedback on physiological functions.

A. Flumazenil B. Chlorpromazine C. Lithium carbonate D. Methadone

Correct Answer is A

Explanation

Choice A Reason:

Flumazenil is a benzodiazepine receptor antagonist used to reverse the effects of benzodiazepines like diazepam. It works by competitively inhibiting the action of benzodiazepines at the GABA receptor, thereby reversing sedation and other effects. Flumazenil is typically administered in cases of benzodiazepine overdose to counteract the sedative effects and restore normal respiratory function. However, it should be used cautiously as it can precipitate withdrawal and seizures in patients with long-term benzodiazepine use.

Choice B Reason:

Chlorpromazine is an antipsychotic medication primarily used to treat schizophrenia and other psychotic disorders. It is not indicated for the treatment of benzodiazepine overdose. Chlorpromazine works by blocking dopamine receptors in the brain, which helps to manage symptoms of psychosis but does not counteract the effects of benzodiazepines. Therefore, it would not be an appropriate choice in this scenario.

Choice C Reason:

Lithium carbonate is a mood stabilizer commonly used in the treatment of bipolar disorder. It helps to reduce the severity and frequency of mania and can also help to relieve or prevent bipolar depression. Lithium does not have any antagonistic effects on benzodiazepines and is not used in the treatment of benzodiazepine overdose. Thus, it would not be the correct medication to administer in this case.

Choice D Reason:

Methadone is a long-acting opioid used for pain management and as part of medication-assisted treatment for opioid use disorder. It works by binding to the same receptors in the brain as other opioids, helping to reduce withdrawal symptoms and cravings. Methadone does not counteract the effects of benzodiazepines and is not used in the treatment of benzodiazepine overdose. Therefore, it would not be an appropriate choice in this scenario.

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A client with schizophrenia approaches the nurse with a look of distress and anguish on his face. He says, “Can’t you hear him? It’s the devil. He’s telling me I’m going to hell.” Which is the most appropriate response by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing a presentation at a community center about complementary and alternative therapies. Which of the following therapies should the nurse describe as the use of an electronic monitoring device to help clients learn to control physical responses to stress?

Correct Answer is A

Explanation

A client is admitted to the Emergency Department (ED) after ingesting a large amount of diazepam. Which medication would the nurse expect the ED physician to order?

Correct Answer is A

Explanation

A client is diagnosed with schizophrenia. The nurse would interpret which behavior as apathy? The client is:

During a morning group meeting, a client raises concern that they cannot sleep at night due to the noises coming from the nurse’s station. The nurse in the meeting interrupts and states, “I’ll handle this matter. Let’s move on.” The nurse is demonstrating which type of leadership style?

A client tells the nurse, “I feel bad because my mother does not want me to return home after I leave the hospital.” Which nursing response is most therapeutic?

The nurse is caring for a client with schizophrenia. Which of the following would be a priority nursing goal for this client’s care?

A nurse is assessing a client who is disoriented to time and place. What additional findings would support a diagnosis of delirium? (Select all that apply.)

A client diagnosed with Illness Anxiety Disorder is prescribed clonazepam for underlying anxiety. Of the following, which is of utmost importance when caring for this client?

The nurse is teaching a client about lorazepam. The nurse should instruct the client to expect which of the following side effects?

When placing an agitated client in restraints, the nurse understands that which of the following must occur?