A nurse is conversing with a client diagnosed with schizophrenia.
Suddenly, the client expresses fear, stating, “I’m scared.
Can you hear that? The voices are instructing me to do awful things.” Which of the following responses from the nurse would be suitable?
Why do you believe you are hearing voices?
What are the voices instructing you to do?
You need to comprehend that there are no voices.
Are the voices familiar to you?
The Correct Answer is B
Choice A rationale:
Asking "Why do you believe you are hearing voices?" is not a suitable response because it challenges the client's reality and can make them feel defensive or invalidated. It's important to validate the client's experience and avoid questioning the reality of their hallucinations.
It can also imply that the client is somehow responsible for their hallucinations, which can be stigmatizing and distressing.
It's more helpful to focus on the content of the hallucinations and how they are affecting the client, rather than on the cause of the hallucinations.
Choice B rationale:
Asking "What are the voices instructing you to do?" is a suitable response because it allows the nurse to assess the content of the hallucinations and the potential for harm.
This information can be used to develop a safety plan and to help the client manage their symptoms.
It also demonstrates to the client that the nurse is taking their concerns seriously and is interested in understanding their experience.
Choice C rationale:
Telling the client "You need to comprehend that there are no voices" is not a suitable response because it is dismissive of the client's experience and can make them feel like they are not being heard or understood.
It's important to remember that hallucinations are very real to the person experiencing them, and telling them that they are not real is not helpful.
It can also damage the therapeutic relationship between the nurse and the client.
Choice D rationale:
Asking "Are the voices familiar to you?" is not a suitable initial response because it is not directly relevant to the client's safety or to the assessment of their symptoms.
While it may be helpful to gather information about the nature of the voices at some point, the priority is to assess the potential for harm and to develop a safety plan.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Meaningless phrases are a hallmark symptom of schizophrenia and can indicate a worsening of the client's psychosis. This is a significant finding because it suggests that the client's ability to think clearly and communicate effectively is deteriorating.
Prompt reporting to the provider is crucial to ensure timely assessment and intervention, which may include medication adjustments or other therapeutic measures to address the worsening psychosis.
Early intervention is essential to prevent further decline in the client's mental state and to minimize the risk of harm to self or others.
I'll provide detailed rationales for the other choices, even though they are not the priority to report:
Choice B rationale:
Refusal to eat can be a symptom of schizophrenia, but it is not as immediate of a concern as meaningless phrases. It's important to monitor the client's nutritional intake and address any underlying causes of the refusal to eat, but this can typically be managed through nursing interventions without requiring immediate provider notification.
Choice C rationale:
Substance use can exacerbate schizophrenia symptoms and should be addressed, but it is not the priority to report in this scenario. The nurse should assess the client's substance use history and patterns, provide education and counseling on the risks of substance use, and collaborate with the provider to develop a treatment plan that addresses both the schizophrenia and the substance use.
Choice D rationale:
Decreased energy level can be a symptom of schizophrenia, but it is also a common symptom of many other conditions. It's important to assess the client's overall health and identify any potential causes of the decreased energy level, but it is not typically a priority to report to the provider unless it is severe or accompanied by other concerning symptoms
Correct Answer is A
Explanation
Answer and explanation
Choice A rationale:
Impaired judgment is a cognitive symptom of schizophrenia, not a positive symptom. It involves difficulties with decisionmaking, problem-solving, and understanding consequences. While it's a significant feature of schizophrenia, it doesn't reflect an excess or distortion of normal functions, which is the hallmark of positive symptoms.
Choice B rationale:
Dysphoria refers to a depressed mood or a state of unhappiness and dissatisfaction. It's a negative symptom of schizophrenia, characterized by a decrease or absence of normal functions. It's not considered a positive symptom as it doesn't involve an excess or distortion of normal processes.
Choice C rationale:
Disorganized speech is a hallmark positive symptom of schizophrenia. It involves significant disruptions in the way a person speaks and communicates. It can manifest in several ways, including: Derailment: Abrupt shifts in topic without logical connection
Tangentiality: Responding to questions in irrelevant or oblique ways
Incoherence: Speech that is fragmented and difficult to understand
Loose associations: Combining words or phrases in a way that lacks logical sense
Neologisms: Creating new words or phrases that have meaning only to the speaker
Word salad: Severely disorganized speech that is essentially incomprehensible
Disorganized speech is considered a positive symptom because it reflects an excess or distortion of normal speech processes. It's a core feature of schizophrenia and often has a significant impact on communication and social functioning.
Choice D rationale:
Anhedonia is the inability to experience pleasure. It's a negative symptom of schizophrenia, characterized by a decrease or absence of normal emotional responses. It's not considered a positive symptom as it doesn't involve an excess or distortion of normal processes.
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