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. Blood pressure 110/70 B. heart rate 86 C. Hypoactive bowel sounds D. Increased restlessness E. Negative Homan's sign

Correct Answer is ["D"]

Explanation

a. Blood pressure 110/70: This is within normal range for many individuals and is not immediately concerning in the post-operative context.
b. heart rate 86: This is a normal heart rate for most individuals and is not concerning post-operatively.
c. Hypoactive bowel sounds: Hypoactive bowel sounds are common post-operatively due to anesthesia and are not immediately concerning.
d. Increased restlessness Increased restlessness can be a sign of pain, anxiety, hypoxia, or other complications and should be addressed promptly.
e. Negative Homan's sign: A negative Homan’s sign indicates no apparent deep vein thrombosis and is a positive finding.

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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

A new nurse orientee asks why a client admitted to the psychiatric unit is placed in seclusion. The nurse precepting the new nurse explains that which of the following is a benefit of seclusion?

Correct Answer is C

Explanation

The nurse is assessing the status of a post-operative client in the PACU. The nurse should be most concerned with which assessment finding?

Correct Answer is ["D"]

Explanation

A nurse working in a mental health unit reviews therapeutic and non-therapeutic communication techniques with a student nurse. All of the following are therapeutic communication techniques except:

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