A nurse is caring for a client who has schizophrenia and begins to talk about fantasy subjects. Which of the following is an appropriate intervention by the nurse?
Encourage the client to focus on reality-based issues.
Ask the client to explain the meaning behind what he is saying.
Persuade the client that his thoughts are not true.
Allow the client to continue talking so as not to interrupt the delusion.
The Correct Answer is A
Choice A reason: Encouraging focus on reality-based issues helps redirect the client gently without reinforcing delusions. It maintains therapeutic communication while grounding the client.
Choice B reason: Asking for meaning focuses attention on the delusion, reinforcing it rather than redirecting.
Choice C reason: Persuading the client that thoughts are not true is confrontational and ineffective. Clients with schizophrenia may not accept reality testing when actively delusional.
Choice D reason: Allowing continued delusional talk reinforces psychosis and does not promote reality orientation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Suspected abuse must be reported immediately according to mandated reporting laws and agency guidelines. This ensures the client’s safety and initiates protective interventions.
Choice B reason: Waiting until the next visit delays action and places the client at continued risk.
Choice C reason: Family therapy may be helpful but is not appropriate until abuse is addressed and safety ensured.
Choice D reason: Increasing visits does not resolve the immediate risk of abuse. Reporting is the priority.
Correct Answer is A
Explanation
Choice A reason: Clients with borderline personality disorder are at high risk for self-harm and suicidal behavior. Protecting the client from self-injury is the priority intervention to ensure safety.
Choice B reason: Redirecting violent behavior is important but secondary to preventing self-harm. Violence may occur, but self-injury is more immediate and life-threatening.
Choice C reason: Encouraging expression of feelings is therapeutic but not the priority when safety is at risk. Emotional exploration can occur after stabilization.
Choice D reason: Exploring reasons for behavior is useful for long-term therapy but is not the immediate priority in acute care.
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