A nurse is caring for a client who has schizophrenia. The client states, "They lie about me all the time and are trying to poison my food." Which of the following responses should the nurse make?

"You seem to be having some very frightening thoughts."

"Why do you think you are being lied about and poisoned?"

"You are mistaken. Nobody is lying about you or trying to poison you."

"Who is lying about you and trying to poison you?"

Answer and Explanation

The Correct Answer is A

Choice A reason: This response acknowledges the client's feelings without agreeing with the delusion or challenging their reality, which can help in building trust and rapport.

Choice B reason: Asking "Why do you think you are being lied about and poisoned?" could potentially reinforce the delusion and lead the client to further justify their beliefs.

Choice C reason: Directly telling the client they are mistaken can be confrontational and may damage the therapeutic relationship.

Choice D reason: Asking "Who is lying about you and trying to poison you?" can validate the delusion and is not a therapeutic response.

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Correct Answer is C

Explanation

Choice A reason: An illusion is a misinterpretation of a real external stimulus, which is not the case here as there is no snake.

Choice B reason: Attention-getting behavior is a possibility, but given that Mr. G is specifically referencing a snake that isn't there, it suggests a hallucination.

Choice C reason: A hallucination is a sensory perception in the absence of external stimuli, which fits Mr. G's description of seeing a snake that isn't there.

Choice D reason: A delusion is a firmly held false belief; while Mr. G may have this, the immediate experience he's describing is a hallucination, not a delusion.

A. Phobia B. Post-Traumatic Stress Disorder (PTSD) C. Somatic Symptom Disorder (SSD) D. Generalized Anxiety Disorder (GAD)

Correct Answer is C

Explanation

Choice A reason: Phobia is an anxiety disorder characterized by an excessive and irrational fear of specific objects, situations, or activities, which does not align with Ms. T's symptoms.

Choice B reason: PTSD is a disorder that can occur after a person has been through a traumatic event, which is not indicated in Ms. T's case.

Choice C reason: SSD is characterized by an extreme focus on physical symptoms, such as pain, that causes major emotional distress and problems functioning, which matches Ms. T's experience.

Choice D reason: GAD involves persistent and excessive worry about various things, not just physical symptoms, so it is less likely than SSD in this scenario.

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A nurse is caring for a client who has schizophrenia. The client states, "They lie about me all the time and are trying to poison my food." Which of the following responses should the nurse make?

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