A client diagnosed with schizophrenia spectrum disorder states, "Can't you hear him? It's the devil. He's telling me I'm going to hell." Which is the most appropriate nursing response?
1. "Did you take your medicine this morning?"
2. "You are not going to hell. You are a good person."
3. "The voices must sound scary, but the devil is not talking to you. This is part of your illness."
4. "The devil only talks to people who are receptive to his influence."
3
Rationale: The most appropriate nursing response is to reassure the client while not reinforcing the hallucination. Reminding the client that "the voices" are a part of the illness is a way to help the client accept that the hallucinations are not real. It is also important for the nurse to connect with the client's fears and inner feelings.
You might also like to view...
A nurse is caring for a patient with a broken tibia and fibula. The patient is in a half cast to his knee and is unable to bear weight. The nurse has instructed the patient on how to walk and climb stairs with his injuries
What is the best way to assess the patient's knowledge of how to ascend and descend stairs? a. Incorrectly re-demonstrate the procedure and have the patient point out any errors. b. Have the family member explain the procedure. c. Have the patient explain the procedure. d. Have the patient demonstrate the procedure.
A father of a preschool-age child tells the nurse that his child "has had a constant cold since going to daycare." How would the nurse respond?
A) "Your child must have a health problem that needs medical care." B) "Children in daycare have more exposure to colds." C) "Are you washing your hands before you touch the child?" D) "Be sure and have your child wear a protective mask at school."
During adolescence, the process of value formation is profoundly influenced by:
A) school administration. B) work. C) awareness of other cultures. D) peers.
MC Early symptoms of hypoxia include 1) Polycythemia. 2) Restlessness. 3) Visual disturbances. 4) Bradycardia
A. 1, 2, 4 B. 1, 4 C. 2, 3 D. 2, 4