A client with schizophrenia tells the nurse that he knows the doctor is trying to kidnap him and sell him as a slave. Which of the following responses by the nurse are therapeutic? (Select all that apply.)

I think you should give the doctor a chance.

Tell me more about your feelings towards the doctor.

That is absolutely not true, sir

Why would the doctor want to do that?

You seem to be worried about seeing the doctor.

Answer and Explanation

Correct Answer : B,E

A. I think you should give the doctor a chance:
This response is not therapeutic because it dismisses the client's feelings and does not address the underlying issue. Telling the client to "give the doctor a chance" minimizes the client's fears and can be perceived
as invalidating. Acknowledging the client’s delusion or belief, rather than trying to directly convince them it is wrong, would be more appropriate.

B. Tell me more about your feelings towards the doctor:
Encouraging the client to elaborate on their feelings is a therapeutic approach that shows the nurse’s willingness to listen without judgment. This allows the nurse to gain insight into the client’s thought process and helps establish trust. It also helps the nurse to assess the severity of the delusion and the client's emotional state related to the belief.

C. That is absolutely not true, sir:
This response is confrontational and may escalate the client's anxiety or distress. Directly disputing the delusion can reinforce the client's sense of mistrust and can contribute to the client feeling misunderstood. It’s important to avoid challenging or arguing with delusions, as this can harm the therapeutic relationship.

D. Why would the doctor want to do that?:
This response may unintentionally reinforce the delusion by focusing on the specifics of the false belief. Instead of helping the client explore their feelings in a therapeutic way, it might lead them to rationalize or elaborate on their delusion further. It's better to focus on the client's emotional state rather than engaging with the content of the delusion.

E. You seem to be worried about seeing the doctor:
This response acknowledges the client’s emotional state and validates their feelings. It does not challenge or argue with the delusion but redirects the conversation to the client's anxiety or fear, which is an appropriate way to approach a client with schizophrenia. It opens up space for the client to discuss their concerns in a non-confrontational manner.

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Correct Answer is B

Explanation

A) The client has gained 1.4 kg (3 lb) in the past month: Weight gain can be a side effect of clozapine, but a 3-pound gain over the course of a month is not an immediate concern. The nurse should continue to monitor the client's weight, but this alone is not a reason to withhold clozapine.

B) The client reports a sore throat: A sore throat could be a sign of a serious side effect of clozapine—agranulocytosis, a condition in which the body has a dangerously low white blood cell count, increasing the risk of infection. The nurse should withhold the medication and notify the healthcare provider immediately if the client reports a sore throat, as this is a potential early sign of agranulocytosis. A complete blood count (CBC) should be checked before continuing the medication.

C) The client reports being constipated for 2 days: Constipation is a common side effect of clozapine due to its anticholinergic properties. While the nurse should address constipation and encourage interventions like increased fluid intake or stool softeners, it is not a reason to withhold clozapine unless the constipation becomes severe or leads to other complications like bowel obstruction.

D) The client reports feeling dizzy when getting out of bed: Dizziness, particularly upon standing (orthostatic hypotension), is a common side effect of clozapine. The nurse should assess the severity of the dizziness and encourage the client to rise slowly from a sitting or lying position, but dizziness alone is not a reason to withhold the medication. However, if the dizziness is severe or persists, the nurse should notify the healthcare provider.

A. I will sit here with you for 10 minutes. B. will find someone else for you to talk with. C. I will come back a little bit later D. I will get you something to read

Correct Answer is A

Explanation

A) I will sit here with you for 10 minutes: This response is the most therapeutic because it shows the nurse’s willingness to be present with the client without pressuring them for interaction. Sitting quietly with the client provides comfort and reassurance, acknowledging their feelings while respecting their need for space. It is important for clients with depression to feel supported, even if they cannot engage in conversation at the moment.

B) I will find someone else for you to talk with: While this response may seem considerate, it could be interpreted as abandoning the client or suggesting they are not worthy of the nurse's attention. The client might feel more isolated or rejected. The priority is to offer comfort and consistency, not to remove oneself from the situation immediately.

C) I will come back a little bit later: While giving the client some time and space is important, this response may not be as therapeutic as simply remaining with the client. It suggests the nurse is unwilling to be present now, which could make the client feel neglected. It’s better to offer calm and supportive presence at the moment, rather than withdrawing.

D) I will get you something to read: Offering something to read can be helpful for some clients, but in this situation, where the client is displaying a flat affect and psychomotor retardation, this response may be too focused on distracting or diverting the client from their emotional state. The priority is to stay with the client and offer a calm, supportive presence rather than immediately introducing distractions.

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A client with schizophrenia tells the nurse that he knows the doctor is trying to kidnap him and sell him as a slave. Which of the following responses by the nurse are therapeutic? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is taking clozapine. For which of the following findings should the nurse withhold the medication?

Correct Answer is B

Explanation

The client exhibits a flat affect, psychomotor retardation, and a depressed mood. The nurse attempts to engage the client in an interaction, but the client does not respond to the nurse. Which response by the nurse is most therapeutic?

Correct Answer is A

Explanation

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