Parents ask a nurse how they should reply when their child, diagnosed with schizophrenia disorder, tells them that voices command the child to harm others. Which is the appropriate nursing response?

"Focus on the feelings generated by the hallucinations and present reality."

Ignore what they are saying, while attempting to discover the underlying cause."

"Present objective evidence that the voices are not real."

Tell them to stop discussing the voices.

Answer and Explanation

The Correct Answer is A

a. "Focus on the feelings generated by the hallucinations and present reality." This approach validates the child's experience and feelings while gently orienting them to reality, which is a therapeutic communication technique.
b. "Ignore what they are saying, while attempting to discover the underlying cause." Ignoring the child’s statements can make them feel dismissed and could increase their distress. It is important to address their experience directly and compassionately.
c. "Present objective evidence that the voices are not real." Presenting objective evidence may not be effective as the child’s belief in the voices can be very strong, and this approach may lead to further agitation.
d. "Tell them to stop discussing the voices." This approach is dismissive and does not help the child manage their symptoms or feel understood. It is important to engage with the child’s experience constructively.

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Correct Answer is C

Explanation

a. The unit can be managed with fewer staff. Seclusion requires close monitoring by staff.
b. Clients are encouraged to communicate with others. Seclusion is meant to be a temporary measure to prevent further harm, not necessarily to promote communication.
c. The reduced sensory input allows the client to regain control. Seclusion is a time-limited safety intervention used when a client poses a danger to themselves or others. It provides a safe space with reduced stimulation to allow the client to calm down and regain control.
d. Clients are forced to be responsible for themselves. Seclusion is not a punitive measure. The goal is to ensure safety and facilitate regaining control.

A. Altered thought processes; call an emergency treatment team meeting. B. Command hallucinations; warn the psychiatrist. C. Persecutory delusions; orient the client to reality. D. Magical thinking; administer an antipsychotic medication.

Correct Answer is B

Explanation

a. Altered thought processes; call an emergency treatment team meeting. While altered thought processes are present, the urgent concern is the command hallucination directing the client to harm the psychiatrist. An emergency treatment team meeting may not provide the immediate intervention required.
b. Command hallucinations; warn the psychiatrist. This is correct because the client is experiencing command hallucinations that pose a direct threat to the psychiatrist. The nurse has a duty to warn the potential victim and ensure the safety of both the client and others.
c. Persecutory delusions; orient the client to reality. Persecutory delusions are present, but the immediate danger from the command hallucinations takes precedence. Orienting the client to reality does not address the urgent safety issue.
d. Magical thinking; administer an antipsychotic medication. Magical thinking is not the correct symptom here. Administering medication is part of treatment but does not address the immediate safety concern.

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Parents ask a nurse how they should reply when their child, diagnosed with schizophrenia disorder, tells them that voices command the child to harm others. Which is the appropriate nursing response?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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