A nurse notices that a client with paranoid schizophrenia stops in mid-sentence when talking and tilts his head to the side as if to listen. The most appropriate intervention by the nurse would be to:
Ask the client, “What are the voices saying to you?”
Give the client a PRN dose of benztropine.
Call and report the behavior to the physician.
Tell the client, “Well, I see you’re distracted right now. We’ll talk more later.”
The Correct Answer is A
The correct answer is a.
Choice A Reason:
The statement “Ask the client, ‘What are the voices saying to you?’” is correct. Engaging the client in a conversation about their hallucinations can help the nurse understand the content and nature of the hallucinations, which is crucial for assessing the client’s risk of harm to themselves or others. This approach also validates the client’s experience and can help build trust and rapport. It is important to approach the client with empathy and without judgment, as this can help in managing the symptoms more effectively.

Choice B Reason:
The statement “Give the client a PRN dose of benztropine” is incorrect. Benztropine is an anticholinergic medication used to treat extrapyramidal symptoms caused by antipsychotic medications. It is not used to manage auditory hallucinations directly. Administering benztropine without a clear indication could lead to unnecessary side effects and does not address the immediate issue of the hallucinations.
Choice C Reason:
The statement “Call and report the behavior to the physician” is incorrect. While it is important to keep the physician informed about significant changes in the client’s condition, the immediate intervention should focus on addressing the client’s current experience. Reporting the behavior without first attempting to understand and manage the hallucinations may delay appropriate care and support for the client.
Choice D Reason:
The statement “Tell the client, ‘Well, I see you’re distracted right now. We’ll talk more later.’” is incorrect. This response dismisses the client’s current experience and may make them feel misunderstood or ignored. It is important to address the client’s immediate needs and provide support rather than postponing the conversation. Acknowledging the client’s experience and offering to discuss it can help in managing the symptoms and providing appropriate care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Seclusion is used in psychiatric settings primarily to manage patients who are exhibiting aggressive or severely disturbed behavior. The reduced sensory input in a seclusion room helps the patient to regain control over their emotions and behavior by minimizing external stimuli that could exacerbate their condition. This controlled environment can be crucial in preventing harm to the patient and others, and it allows the patient to calm down in a safe space. The goal is to provide a therapeutic setting that aids in the patient’s recovery and stabilization.
Choice B Reason:
While communication is an essential part of psychiatric care, seclusion is not intended to encourage interaction with others. In fact, seclusion is used when a patient needs to be isolated to prevent harm to themselves or others. Encouraging communication is more appropriate in other therapeutic settings where the patient is stable and can engage safely with others. Therefore, this statement does not accurately explain the purpose of seclusion.
Choice C Reason:
Forcing clients to be responsible for themselves is not the primary goal of seclusion. Seclusion is a measure taken to ensure safety and to help the patient regain control over their behavior in a controlled environment. Responsibility and self-management are important aspects of psychiatric treatment, but they are typically addressed through other therapeutic interventions and not through seclusion. Thus, this statement is not an accurate explanation of the use of seclusion.
Choice D Reason:
Managing the unit with fewer staff is not a valid reason for using seclusion. The primary purpose of seclusion is to ensure the safety of the patient and others, not to reduce staffing needs. In fact, the use of seclusion requires careful monitoring and adherence to strict protocols, which can actually increase the need for staff attention. Therefore, this statement does not correctly explain the rationale behind the use of seclusion.
Correct Answer is A
Explanation
Choice A Reason:
The client diagnosed with a somatoform disorder should have any new medical complaint evaluated.
This is the correct response. Clients with somatoform disorders often experience physical symptoms that cannot be fully explained by any underlying medical condition. However, it is crucial to evaluate any new medical complaints to rule out any actual medical conditions that may require treatment. This approach ensures that the client receives comprehensive care and that any potential medical issues are not overlooked.

Choice B Reason:
The client diagnosed with a somatoform disorder can be easily cured with medication.
This statement is incorrect. Somatoform disorders are complex and often require a multifaceted treatment approach, including psychotherapy, behavioral interventions, and sometimes medication to manage associated symptoms like anxiety or depression. There is no simple cure for somatoform disorders, and treatment typically focuses on managing symptoms and improving the client’s quality of life.
Choice C Reason:
The client diagnosed with a somatoform disorder has a real medical diagnosis for their symptoms.
While clients with somatoform disorders experience real and distressing symptoms, these symptoms are not typically linked to a diagnosable medical condition. The symptoms are believed to be related to psychological factors, and the focus of treatment is often on addressing these underlying psychological issues rather than finding a medical diagnosis.
Choice D Reason:
The client diagnosed with a somatoform disorder intentionally pretends to have physical symptoms.
This statement is incorrect. Clients with somatoform disorders do not intentionally fake their symptoms. Their symptoms are real to them and cause significant distress and impairment. The symptoms are not under the client’s conscious control, and they genuinely believe they are experiencing a medical condition.
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