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?”
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E"]
Explanation
Answer and explanation
The correct answers are choices A. Depression, B. Obsessive-compulsive disorder, E. Anxiety.
Choice A rationale:
Depression commonly coexists with eating disorders. The individual's distorted body image, feelings of low self-worth, and dietary restrictions can contribute to the development of depressive symptoms.
Choice B rationale:
Obsessive-compulsive disorder (OCD) often occurs alongside eating disorders. The obsessions and compulsions seen in OCD can overlap with behaviors related to food, eating rituals, and body image, reinforcing the eating disorder pathology.
Choice C rationale:
Schizophrenia is not typically considered a comorbidity of eating disorders. Schizophrenia involves disruptions in thought processes, emotions, and perceptions, which are distinct from the cognitive distortions and behaviors associated with eating disorders.
Choice D rationale:
Breathing-related sleep disorder is not a commonly recognized comorbidity of eating disorders. While sleep disturbances might occur in individuals with eating disorders due to physical discomfort or anxiety, a specific link to breathing-related sleep disorder is less established.
Choice E rationale:
Anxiety is a well-recognized comorbidity of eating disorders. Anxiety often accompanies the intense fears, worries, and preoccupations related to body weight, shape, and eating behaviors that are characteristic of eating disorders.
Correct Answer is A
Explanation
The correct answer is choice A: Set limits for the relationship.
Choice A rationale:
Setting limits for the therapeutic relationship (Choice A) is an essential nursing action. Boundaries help create a safe and structured environment, ensuring that both the nurse and client maintain appropriate roles. Limits prevent overstepping boundaries that could compromise the therapeutic alliance.Setting limits for the relationship is an essential part of establishing a therapeutic relationship in a mental health setting. This helps to maintain professional boundaries and ensures that the relationship remains focused on the client’s needs and therapeutic goals.
Choice B rationale:
Engaging in affectionate interactions with the client (Choice B) is not appropriate in a therapeutic relationship. Professionalism and maintaining appropriate boundaries are crucial in psychiatric nursing. Affectionate interactions could blur the lines between the therapeutic relationship and personal relationships, potentially harming the client's progress.
Choice C rationale:
Promoting the use of transference by the client (Choice C) is not a suitable approach. Transference occurs when a client projects feelings and emotions onto the nurse based on past experiences. While it can be valuable to explore transference, actively promoting it could lead to confusion and misunderstandings in the therapeutic relationship.
Choice D rationale:
Instructing the client on how they should behave (Choice D) is contrary to the principles of a therapeutic relationship. The therapeutic relationship is client-centered, where the nurse supports the client's self-discovery and growth. Directing the client's behavior undermines their autonomy and inhibits their progress.
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