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 D

Explanation

Choice A reason: Setting consequences just before the behavior occurs does not provide clear expectations and boundaries for the patient.

Choice B reason: Setting consequences after the behavior is done may not effectively prevent the behavior and can lead to inconsistent enforcement.

Choice C reason: Waiting for complaints before setting consequences can lead to a reactive rather than proactive approach to care.

Choice D reason: Consequences should be clearly communicated when the limit is set to establish clear boundaries and expectations, which is essential in managing patients with personality disorders.

A. Displacement. B. Projection. C. Regression. D. Reaction formation.

Correct Answer is A

Explanation

Choice A reason: Displacement is a defense mechanism where a person redirects a negative emotion from its original source to a less threatening recipient, which is what Mr. Thomas is doing.

Choice B reason: Projection involves attributing one's own unacceptable feelings or thoughts to others, which is not what Mr. Thomas is doing.

Choice C reason: Regression is a return to earlier stages of development when faced with stress, which does not describe Mr. Thomas's behavior.

Choice D reason: Reaction formation involves behaving in a way that is opposite to what one truly feels, which is not indicated 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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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