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A delusional client has refused to eat for the past 24 hours because, he says,
"the food is poisoned." How should the nurse respond?
1
"Why do you think that the food is poisoned?"
Correct2
"You feel worried that someone wants to
poison you?" 3
"This feeling is a symptom of your illness. It's
not real." 4
"You'll be safe with me. I won't let anyone poison you."
It is important to help the client focus on feelings, and "You feel worried that
someone wants to poison you?" is the only response that helps achieve this goal.
Why questions call for a conclusion rather than an exploration of the issue; the
client may not have the answer. Although stating that the feeling is a symptom of
the client's illness is true, it is not something that the client is ready to
understand; also, it is a closed statement. "You'll be safe with me. I won't let
anyone poison you" is false reassurance and is not realistic; the client still is
concerned about what will happen when the nurse is not there.
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question? 22.
A client on the psychiatric unit tells the nurse, "The voices have told me that I'm
in danger. They say I'll be safe only if I stay in this room, wear these clothes, and
avoid stepping on the cracks between the floor tiles." What is the best initial
response by the nurse?
NURS 557 Adaptive Quiz Psychosis Exam Questions
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,NURS 557 Adaptive Quiz Psychosis Exam Questions
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1
"Don't worry. You're safe here. Are you afraid that I'll let someone hurt you?"
Correct2
"I know that these voices are real to you, but I want you to know that I don't
hear them." 3
"Tell me more about the voices. Are they male or female? How many voices
do you hear?" 4
"You need to leave this room and get your mind occupied so the voices
don't bother you anymore."
"I know that these voices are real to you, but I want you to know that I don't hear
them" demonstrates recognition and acceptance of the client's feelings and also
points out reality. "Don't worry. You're safe here. Are you afraid that I will let
someone hurt you?" provides false reassurance; the client has no reason to trust
that the nurse can provide protection. Focusing on the content of the delusion will
reinforce the delusion. Encouraging the client to focus on hallucinations tends to
strengthen and confirm them. "You need to leave this room and get your mind
occupied so the voices don't bother you anymore" denies the client's feelings and
may increase anxiety.
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question? 23.
A couple arrives at the mental health clinic for counseling because the husband
consistently believes that his wife is having multiple affairs. After several
sessions a delusional disorder is diagnosed. What specific subtype of the
delusion does the nurse identify?
NURS 557 Adaptive Quiz Psychosis Exam Questions
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,NURS 557 Adaptive Quiz Psychosis Exam Questions
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Correct
1
Jealous
y2
Somat
ic 3
Grandio
se 4
Persecutory
A client who is convinced that a mate is unfaithful exhibits delusional jealousy.
Somatic delusions concern preoccupation with the body, including complaints
of disfigurement, nonfunctioning body parts, insect infestation, and presence of a
serious illness. In a grandiose delusion, the client seeks a position of power by
expressing an exaggerated belief in his or her importance or identity. Clients with
persecutory delusions believe that they are being conspired against, spied on,
drugged, or poisoned.
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A nurse is managing the care of a client with recently diagnosed schizophrenia.
Effective therapeutic communication will directly affect which client-focused
outcomes? Select all that apply.
1
The client will become capable of part-time
employment. Correct 2
The client will effectively express emotional and
NURS 557 Adaptive Quiz Psychosis Exam Questions
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physical needs. 3
The client will demonstrate wellness reflective of
physical potential. Correct 4
The client will demonstrate an understanding of the mental
health disorder. Correct 5
The client will recognize the issues most important to managing this disorder.
Therapeutic communication facilitates the exchange of information between the
nurse and the client that focuses on the client's attaining health and wellness. This
information can be directed towards the client's health needs such as the effective
expression of the client's physical and emotional needs, the understanding of the
cause and prognosis of the current mental health
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