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","C","D"]

Explanation

Choice A Reason:

Use a calm voice.

Using a calm voice is essential in de-escalating an agitated client. A calm and steady tone can help soothe the client and reduce their anxiety. It also demonstrates that the nurse is in control of the situation and is there to help, which can be reassuring for the client.

Choice B Reason:

Speak louder than the client so as to be heard.

Speaking louder than the client is not appropriate as it can escalate the situation further. Raising one’s voice can be perceived as confrontational and may increase the client’s agitation. It is important to maintain a calm and composed demeanor to help de-escalate the situation.

Choice C Reason:

Reduce stimuli for the client.

Reducing stimuli is an effective intervention for an agitated client. Excessive noise, bright lights, and other environmental stimuli can exacerbate agitation. Creating a quieter and more controlled environment can help the client feel more at ease and reduce their agitation.

Choice D Reason:

Attempt to redirect the client.

Attempting to redirect the client can be helpful in de-escalating agitation. Redirecting the client’s attention to a different topic or activity can help distract them from the source of their agitation and provide a sense of control. This technique can be effective in calming the client and preventing further escalation.

Choice E Reason:

Reprimand the client for upsetting everyone.

Reprimanding the client is not an appropriate intervention. It can increase the client’s feelings of frustration and agitation. Instead, the focus should be on understanding the client’s needs and providing support to help them calm down.

A. Recommend the client distance themselves from people who knew them before their diagnosis. B. Provide the client with a multi-step written plan to follow if auditory hallucinations occur. C. Risperidone as a depot formulation every 2 weeks. D. Increase white bread and bananas to help with anticholinergic symptoms. E. Assist the client to enroll in a program of assertive community treatment.

Correct Answer is ["B","C","E"]

Explanation

Choice A Reason:

Recommending the client distance themselves from people who knew them before their diagnosis is not a suitable measure for tertiary prevention. Tertiary prevention aims to reduce the impact of an ongoing illness by helping patients manage long-term, complex health problems and injuries. It focuses on improving quality of life and reducing symptoms. Distancing from familiar people could lead to social isolation, which might worsen the client’s condition.

Choice B Reason:

Providing the client with a multi-step written plan to follow if auditory hallucinations occur is a practical measure for tertiary prevention. This plan can help the client manage symptoms effectively and reduce the likelihood of hospitalization. It empowers the client to take control of their symptoms and provides clear steps to follow during a crisis, which can be crucial for maintaining stability.

Choice C Reason:

Risperidone as a depot formulation every 2 weeks is an effective measure for ensuring medication adherence in clients with schizophrenia. Depot formulations are long-acting injections that help maintain consistent medication levels in the body, reducing the risk of relapse due to missed doses. This approach is particularly beneficial for clients who have difficulty adhering to daily oral medication regimens.

Choice D Reason:

Increasing white bread and bananas to help with anticholinergic symptoms is not a recommended measure for managing schizophrenia. While diet can play a role in overall health, there is no evidence to suggest that these specific foods help with anticholinergic symptoms. Anticholinergic symptoms are typically managed with medications and other medical interventions.

Choice E Reason:

Assisting the client to enroll in a program of assertive community treatment (ACT) is a highly effective measure for tertiary prevention. ACT provides comprehensive, community-based psychiatric treatment, rehabilitation, and support to individuals with serious and persistent mental illnesses. This approach helps clients manage their symptoms, adhere to treatment plans, and reduce the risk of hospitalization by providing continuous, personalized care.

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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

The nurse is attempting to de-escalate a client who is becoming increasingly agitated on the unit. Which of the following interventions would be appropriate for this type of client? (SELECT ALL THAT APPLY)

Correct Answer is ["A","C","D"]

Explanation

A client with schizophrenia has had 2 hospitalizations within the past 9 months due to non-adherence to medications and their counseling plan. What measures should the nurse and the mental health treatment team recommend for tertiary prevention? (Select All That Apply)

Correct Answer is ["B","C","E"]

Explanation

A nurse in orientation is rotating to a psychiatric unit where they observe a client in seclusion. Which of the following statements by the nurse’s preceptor best explains the use of seclusion on a unit?

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