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: Conversion typically refers to the expression of psychological distress through physical symptoms, which is not the case here.

Choice B reason: Undoing is a defense mechanism where a person tries to 'undo' an unhealthy thought or behavior with a healthier one, which does not apply to Michael's situation.

Choice C reason: Compensation is a defense mechanism where a person overachieves in one area to make up for deficiencies in another, which describes Michael's actions.

Choice D reason: Sublimation involves channeling unacceptable impulses into socially acceptable activities, which is not explicitly indicated in this scenario.

A. Illusion. B. Attention-getting behavior. C. Hallucination. D. Delusion.

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.

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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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Naxlex Comprehensive Predictor Exams

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