The nurse is observing the interaction between a mother and schizophrenic son. The son states, "The man visiting me said you went on vacation without me." The mother replied, "There is no man, you are just making that up." When interacting with the mother privately, which reply from the mother would the nurse suggest?
"I am not on vacation. I am here with you."
"How can I go on vacation. I do not have any money."
"Stop saying that. You know better. No one told you that."
"Just forget about that and let's talk about something else."
The Correct Answer is A
A. "I am not on vacation. I am here with you." This response calmly reassures the client by affirming the mother’s presence, which helps address the son’s confusion without directly challenging his perception.
B. "How can I go on vacation? I do not have any money." This response could increase confusion and does not address the son's needs effectively. It could also lead to unnecessary discussions that might not be helpful.
C. "Stop saying that. You know better. No one told you that." This response is dismissive and confrontational, which may exacerbate the son’s distress and could damage the therapeutic relationship.
D. "Just forget about that and let's talk about something else." This response avoids addressing the son’s concerns, which can make him feel dismissed and not listened to, potentially worsening his symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "Do you go by he, she, or they?" This question is direct and acknowledges the importance of pronouns, but it might be better phrased to be more open-ended and respectful.
B. "What pronouns do you go by?" This is the most respectful and open-ended approach, allowing the client to express their preferred pronouns without making assumptions. It demonstrates a clear understanding of the importance of gender identity and respects the client's autonomy.
C. "What led to this hospital admission?" While this question is relevant to the client’s care, it does not address the client's gender identity directly, which is crucial in this context.
D. "What brings you in today?" Similar to option C, this question focuses on the reason for the hospital visit but does not address the client's gender identity, missing an opportunity to show respect for their identity.
Correct Answer is B
Explanation
A. Disorganized speech: Disorganized speech involves incoherent or illogical speech patterns, which is not the primary observation here.
B. A hallucination: The client is interacting with an unseen entity, which suggests a hallucination, a false sensory perception, particularly common in schizophrenia.
C. An illusion: An illusion involves a misinterpretation of a real external stimulus, which is not applicable in this situation as there is no stimulus present.
D. Anhedonia: Anhedonia refers to a loss of interest or pleasure in activities, which does not describe the behavior observed.
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