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 ["B","D","E"]

Explanation

Choice A Reason:

The statement “They do not need to report the use of herbal therapies to the provider” is incorrect. It is crucial for clients to inform their healthcare providers about any herbal therapies they are using. This is because herbal therapies can interact with prescription medications, potentially causing adverse effects or reducing the efficacy of the medications. Healthcare providers need to be aware of all substances a patient is taking to provide safe and effective care.

Choice B Reason:

The statement “Herbal therapies also have side effects and may interact with other medications being taken” is correct. Herbal therapies, despite being natural, can have potent effects on the body and may cause side effects. Additionally, they can interact with other medications, leading to potentially harmful interactions. For example, St. John’s wort can interact with antidepressants, and ginkgo biloba can affect blood clotting. Therefore, it is essential to consider these interactions when using herbal therapies.

Choice C Reason:

The statement “They need to stay away from all herbal therapies” is incorrect. While it is important to be cautious, it is not necessary to avoid all herbal therapies. Many herbal therapies can be beneficial when used appropriately and under the guidance of a healthcare provider. The key is to ensure that the herbal products are safe, effective, and do not interact negatively with other medications the client may be taking.

Choice D Reason:

The statement “Herbal therapies should be purchased from reliable manufacturers with a history of quality control of their product” is correct. The quality of herbal products can vary significantly between manufacturers. Choosing products from reputable manufacturers ensures that the products have been tested for purity, potency, and safety. Reliable manufacturers follow good manufacturing practices and have stringent quality control measures in place, reducing the risk of contamination and ensuring the product’s efficacy.

Choice E Reason:

The statement “They should always inform healthcare providers of the use of herbs” is correct. It is essential for clients to inform their healthcare providers about any herbal therapies they are using. This information helps healthcare providers to monitor for potential interactions and side effects, adjust medication dosages if necessary, and provide comprehensive care. Open communication between clients and healthcare providers is crucial for ensuring safe and effective treatment plans.

A. Clear and organized speech B. Increased attention and focus C. Fluctuating levels of consciousness D. Stable and consistent cognitive function E. Agitation and aggression

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

Explanation

The correct answer is c, e.

Choice A Reason:

The statement “Clear and organized speech” is incorrect. Clients with delirium often exhibit disorganized thinking and speech. Their speech may be rambling, irrelevant, or incoherent, reflecting their fluctuating mental state. Clear and organized speech is more characteristic of a person without cognitive impairment or with stable cognitive function.

Choice B Reason:

The statement “Increased attention and focus” is incorrect. Delirium is characterized by a disturbance in attention and awareness. Clients with delirium typically have difficulty sustaining or shifting attention, which is a key diagnostic criterion. Increased attention and focus are not consistent with the presentation of delirium.

Choice C Reason:

The statement “Fluctuating levels of consciousness” is correct. One of the hallmark features of delirium is the fluctuation in the level of consciousness throughout the day3. Clients may experience periods of lucidity interspersed with confusion and disorientation. This fluctuation is a critical diagnostic indicator of delirium.

Choice D Reason:

The statement “Stable and consistent cognitive function” is incorrect. Delirium is marked by an acute change in cognitive function, which is neither stable nor consistent. Cognitive functions such as memory, orientation, and language are typically impaired and fluctuate over time. Stable cognitive function would not support a diagnosis of delirium.

Choice E Reason:

The statement “Agitation and aggression” is correct. Clients with delirium often exhibit behavioral disturbances, including agitation and aggression. These symptoms can result from the confusion and disorientation experienced during delirium. Recognizing these behavioral changes is important for the diagnosis and management of delirium.

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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

During a routine health examination, the client tells the nurse about using a variety of herbal therapies for health maintenance. When discussing the use of herbs, the nurse cautions the client that: (SELECT ALL THAT APPLY)

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

Explanation

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.)

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

Explanation

A client diagnosed with schizophrenia is prescribed clozapine. The nurse teaches the client and family to call the physician immediately if:

The nurse is completing an admission assessment of a client who is admitted to milieu. Which piece of information obtained from the client during the assessment would require immediate investigation from the nurse regarding the client’s use of complementary and alternative therapies?

A young client asks the nurse for their telephone number, with the intent of calling to schedule a date. Which of the following responses would be most appropriate?

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

The nurse calculates that a patient must receive 1.3 mL of an anti-infective agent. The dose is ordered IM. Which of the following choices demonstrates safe, evidence-based practice?

Upon assessment of the lungs, the nurse hears continuous, high-pitched, musical sounds. This should be documented as:

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

A client is admitted to an inpatient unit with a diagnosis of frontotemporal dementia. Which of the following aspects of a medical history would the nurse expect to see with this client? (Select All that Apply.)