The nurse manager of the inpatient psychiatric unit is talking with the staff about the interventions to promote independent actions of clients on the chronic schizophrenia unit

Question

Which of the following responses made by the staff indicates lack of insight into the client's illness? 1. "I want to learn more about the side effects of the medication."
2. "I know when clients hear voices they are not real."
3. "I understand that some clients are not able to put on their clothes."
4. "I believe clients sometimes need to be isolated help them feel safe."

Answer 1

2
Rationale: A hallucination is a real experience to the individual To maintain a therapeutic relationship, the nurse should convey acceptance of the client's experience. Acknowledging disbelief of the auditory hallucination may affect the nurse's ability to engage in a therapeutic nurse–client relationship. Clients who are low functioning may benefit from assistance with their activities of daily living, such as assisting with dressing. A client who is at risk for harming self or others may need to be isolated to help him or her feel safe by minimizing access to potentially harmful objects. Nurses need to be informed of potential side effects of medications in order to monitor for side effects and instructing others.