A nurse is talking with a client diagnosed with schizophrenia. Suddenly the client states, "I'm frightened. Do you hear that? The voices are telling me to do terrible things." Which of the following responses by the nurse is appropriate?

"You need to tell the voices to leave you alone.”

"You need to understand that there are no voices.”

"What are the voices telling you to do?”

"Why do you think you are hearing the voices?”

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Instructing the client to tell the voices to leave them alone oversimplifies the situation. It disregards the distress and lack of control that individuals with schizophrenia often experience when hearing voices. This response may also imply that the client has complete control over the voices, which is not accurate.

Choice B rationale:

Denying the existence of the voices contradicts the client's experience and could lead to further distrust between the client and nurse. Acknowledging the client's feelings and experiences is essential for building rapport and understanding in a therapeutic relationship.

Choice C rationale:

This response is appropriate because it acknowledges the client's experience and seeks to understand the content and nature of the voices. It demonstrates empathy and encourages open communication, which is crucial in providing effective care for individuals with schizophrenia.

Choice D rationale:

Asking the client why they think they are hearing the voices might be interpreted as confrontational or judgmental. It could make the client defensive and hinder open communication. Instead, focusing on the content of the voices allows the nurse to gain insight into the client's experiences without placing blame.

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Correct Answer is B

Explanation

Choice A rationale:

Telling the newly diagnosed cancer clients that they need to work hard on resolving conflicts with those closest to them may come across as insensitive and dismissive of their emotional struggles. Cancer diagnosis often brings about complex emotions, and this response does not acknowledge or address their concerns.

Choice B rationale:

This response acknowledges the client's statement and encourages further discussion about their feelings regarding their inability to return to work. It shows empathy and a willingness to explore their concerns, promoting open communication and emotional support.

Choice C rationale:

Commenting on the client's physical behavior without context might make them uncomfortable or self-conscious. The nurse's observation about fist clenching should be addressed more delicately if relevant, and the focus should be on the emotional aspect rather than the physical behavior.

Choice D rationale:

Dismissing the potential benefit of antidepressants and promoting the therapy group might undermine the client's feelings and choices. While group therapy can be beneficial, this response overlooks the potential need for a multifaceted approach to treatment, which could include therapy and medication.

A. Medicate the client with a sedative. B. Have the client join a therapy group. C. Suggest that the client rest in bed. D. Remain with the client in his room for a while.

Correct Answer is D

Explanation

The correct answer is choice D: "Remain with the client in his room for a while."

Choice D rationale:

This choice is the correct answer because when a client is experiencing panic-level anxiety, their immediate need is for support and reassurance. Staying with the client helps establish a sense of safety and demonstrates the nurse's presence, which can help reduce anxiety. Providing a calming and supportive presence is a therapeutic nursing intervention in this situation.

Choice A rationale:

Medicating the client with a sedative might be appropriate in some cases of severe anxiety, but it should not be the first action taken. Non-pharmacological interventions, such as offering emotional support, should be prioritized before resorting to medication.

Choice B rationale:

Joining a therapy group might be beneficial for the client in the future, but during the acute phase of panic-level anxiety, the client might not be in a state to actively participate and engage in group therapy. Immediate individual attention is necessary.

Choice C rationale:

While suggesting that the client rest in bed could be helpful for relaxation, it might not be sufficient to address the intensity of panic-level anxiety. The client might not be able to rest or calm down without more direct support from the nurse.

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A nurse is talking with a client diagnosed with schizophrenia. Suddenly the client states, "I'm frightened. Do you hear that? The voices are telling me to do terrible things." Which of the following responses by the nurse is appropriate?

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Correct Answer is D

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