A patient diagnosed with schizophrenia tells the nurse, “I hear voices sometimes, but they don’t bother me.” Which of the following is the most appropriate open-ended response by the nurse to further assess the patient’s experience?

Do the voices come from the TV or the radio?

Tell me more about what the voices say to you.

Are the voices telling you to harm yourself or others?

Do you hear the voices more during the day or night?

Answer and Explanation

The Correct Answer is B

Choice A reason: Asking if voices come from external sources like TV assumes a delusional origin and closes off exploration. Open-ended questions are needed to assess the nature and impact of auditory hallucinations in schizophrenia, making this choice nontherapeutic.

Choice B reason: Asking the patient to describe the voices’ content is an open-ended response that encourages detailed disclosure. This helps assess the hallucinations’ nature, frequency, and impact on behavior, aiding in risk assessment and treatment planning, making this the correct choice.

Choice C reason: Asking about harm is a closed-ended question that assumes a specific risk, potentially limiting exploration of the hallucination’s full context. While safety is critical, open-ended questions better assess the patient’s experience initially, making this choice less appropriate.

Choice D reason: Asking about the timing of voices is closed-ended and limits the depth of assessment. Understanding the content and impact of hallucinations is more critical for schizophrenia management, as timing alone does not reveal risk or severity, making this choice incorrect.

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Correct Answer is A

Explanation

Choice A reason: Waxy flexibility, seen in catatonia, involves patients maintaining limbs in fixed positions when placed there, reflecting basal ganglia and prefrontal cortex dysfunction. This passive rigidity is a hallmark of catatonic schizophrenia or mood disorders, making this the correct choice.

Choice B reason: Repetitive, purposeless movements like rocking are stereotypic behaviors, often in autism or anxiety disorders. These active movements differ from the passive, fixed posturing of waxy flexibility in catatonia, making this choice incorrect.

Choice C reason: Rapid, involuntary muscle jerks or spasms are extrapyramidal symptoms, often from antipsychotics affecting dopamine pathways. These are distinct from the sustained, passive limb positioning in waxy flexibility, making this choice incorrect for the described phenomenon.

Choice D reason: Resistance to passive movement followed by release describes cogwheel rigidity, seen in Parkinson’s disease, due to dopamine deficits. Waxy flexibility involves sustained positioning without resistance, making this choice incorrect for the catatonic feature described.

A. The patient is demonstrating signs of ineffective coping and should be referred for psychiatric evaluation B. The patient is showing symptoms of major depressive disorder and requires immediate intervention C. The patient is noncompliant with medical care due to unresolved emotional issues D. The patient is progressing through the normal stages of grief

Correct Answer is A

Explanation

Choice A reason: Withdrawn behavior and avoiding eye contact suggest ineffective coping, as the patient struggles to process missing a treatment. Psychiatric evaluation can assess underlying emotional distress, such as anxiety or depression, and provide targeted interventions, making this the correct choice for addressing the patient’s needs.

Choice B reason: Symptoms like withdrawal could suggest depression, but diagnosing major depressive disorder requires more criteria, such as persistent low mood or anhedonia, not evident here. Immediate intervention assumes severity not supported by the scenario, making this choice less accurate than a referral.

Choice C reason: Labeling the patient as noncompliant assumes intentional refusal, but the scenario suggests emotional distress, not deliberate nonadherence. Withdrawal and avoidance indicate psychological barriers, not noncompliance, making this choice incorrect for the described behavior.

Choice D reason: Normal grief involves stages like denial or sadness, but the scenario lacks evidence of a loss triggering grief. Withdrawal and avoidance suggest coping difficulties, not a clear grief process, making this choice incorrect for the patient’s presentation.

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A patient diagnosed with schizophrenia tells the nurse, “I hear voices sometimes, but they don’t bother me.” Which of the following is the most appropriate open-ended response by the nurse to further assess the patient’s experience?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What is waxy flexibility in psychiatric patients?

Correct Answer is A

Explanation

A patient missed a treatment option. Later, the patient appears withdrawn and avoids eye contact when discussing calling loved ones. Which is the best nursing action?

Correct Answer is A

Explanation

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