A nurse is talking with a client who has schizophrenia. Suddenly the client states, “I’m frightened. Do you hear that? The voices are telling me to do terrible things.” Which of the following responses by the nurse is appropriate?
“What are the voices telling you to do?”
“You need to understand that there are no voices.”
“Why do you think you are hearing the voices?”
“You need to tell the voices to leave you alone.”
The Correct Answer is A
Choice A reason:
Asking “What are the voices telling you to do?” is an appropriate response because it allows the nurse to assess the content of the hallucinations and determine if the client is at risk of harming themselves or others. This approach shows empathy and concern while gathering important information for the client’s safety.
Choice B reason:
Telling the client “You need to understand that there are no voices” dismisses the client’s experience and can increase their distress. It is important to acknowledge the client’s feelings and perceptions, even if they are not based in reality.
Choice C reason:
Asking “Why do you think you are hearing the voices?” may not be helpful in the moment of distress. The client may not be able to provide a rational explanation for their hallucinations, and this question could increase their confusion and anxiety.
Choice D reason:
Telling the client “You need to tell the voices to leave you alone” may not be effective, as the client may not have the ability to control their hallucinations. It is more important to assess the content of the hallucinations and provide support.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is A
Explanation
Choice A reason:
An advance care directive, or “living will,” is a legal document that specifies what medical treatments the client wishes to receive or omit if they become unable to make decisions for themselves. This document guides healthcare providers and family members in making decisions that align with the client’s preferences.
Choice B reason:
A client is not required to sign the “living will” document with an attorney present. While it is advisable to consult with an attorney when creating legal documents, it is not a requirement for the validity of an advance care directive.
Choice C reason:
An attorney may assist in drafting the advance care directive, but it is not necessary for the attorney to draw up the papers. The client can create the document with the help of healthcare providers or legal advisors.
Choice D reason:
The client’s physician does not need to act as a witness when the client signs the document. Typically, witnesses are required to ensure the document is signed voluntarily and without coercion, but they do not have to be the client’s physician.
Correct Answer is B
Explanation
Choice A reason:
The 24-year-old only being the client would imply that the therapy session is focused solely on the individual issues of the 24-year-old. However, the context of the therapy session, which includes multiple family members, suggests that the focus is on addressing family dynamics and conflicts. Family therapy typically involves working with the entire family unit to improve relationships and resolve conflicts, rather than focusing on a single individual.
Choice B reason:
The entire family being the client is the correct answer because family therapy aims to address issues within the family system as a whole. By involving the 24-year-old, his sister, his mother, and the mother’s live-in boyfriend, the therapy session is designed to explore and resolve conflicts that affect the entire family. This approach recognizes that individual issues are often interconnected with family dynamics, and addressing these dynamics can lead to more effective and lasting solutions.
Choice C reason:
The 24-year-old and his mother being the clients would limit the scope of the therapy to the relationship between these two individuals. While this might address some aspects of the family conflict, it would not provide a comprehensive approach to resolving issues that involve other family members, such as the sister and the mother’s live-in boyfriend. Family therapy is most effective when all relevant members are included in the process.
Choice D reason:
The sister, mother, and 24-year-old being the clients would exclude the mother’s live-in boyfriend, who is also part of the family dynamic. Excluding any family member who is involved in the conflict can limit the effectiveness of the therapy. Family therapy aims to include all relevant members to fully understand and address the issues affecting the family as a whole. Therefore, this option is not as comprehensive as involving the entire family.