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?"
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D"]
Explanation
Choice A reason: Lack of interest is a negative symptom of schizophrenia, characterized by a diminished ability to initiate and sustain planned activities.
Choice B reason: Hyperactivity is not typically considered a negative symptom of schizophrenia.
Choice C reason: Delusions are considered positive symptoms, not negative symptoms of schizophrenia.
Choice D reason: Neglect of personal hygiene is a negative symptom, reflecting a decrease in the ability to manage personal self-care.
Choice E reason: Irrational actions are more aligned with positive symptoms due to their active nature.
Correct Answer is A
Explanation
Choice A reason: Catatonia is characterized by symptoms such as extreme muscle rigidity, repetitive speech, and resistance to movement, which align with Lisa's presentation. It is often associated with other mental health conditions but can also be a standalone diagnosis.
Choice B reason: Disorganized schizophrenia is marked by disorganized thinking and behavior, inappropriate emotional responses, and erratic actions. While Lisa's symptoms could suggest a psychotic disorder, they do not specifically indicate disorganized schizophrenia.
Choice C reason: Schizotypal disorder involves eccentric behavior, odd beliefs, and difficulty forming close relationships. Lisa's symptoms do not align with the core characteristics of schizotypal disorder.
Choice D reason: Brief psychotic disorder is a short-term condition that includes delusions, hallucinations, and disorganized speech. Lisa's symptoms could be part of a brief psychotic episode, but the specific mention of muscle rigidity and resistance to movement is more indicative of catatonia.
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