which response would the nurse make to a client with schizophrenia who claims to be joan of arc about to be burned at the stake
Logo

Nursing Elites

NCLEX-RN

NCLEX Psychosocial Integrity Questions

1. Which response would the nurse make to a client with schizophrenia who claims to be Joan of Arc about to be burned at the stake?

Correct answer: C

Rationale: The nurse would say, ''It seems like the world is a pretty scary place for you.'' This response allows the nurse to understand the symbolism, reflect on and acknowledge the client's feelings, and help preserve the client's integrity. The statement, ''Tell me more about being Joan of Arc,'' validates the client's delusion and does not test reality. The statement, ''We both know that you're not Joan of Arc,'' rejects the client's feelings and does not address the client's fears of being harmed; clients cannot be argued out of delusions. The statement, ''You're safe here, because we won't let you be burned,'' is false reassurance; the nurse is agreeing with the client's false perceptions of reality, which is nontherapeutic.

2. A man who is admitted for a suicide attempt after the death of his child says, 'I hear my son telling me to come over to the other side.' Which psychotic symptom is the client experiencing?

Correct answer: D

Rationale: The client is experiencing a command hallucination. Command hallucinations involve auditory messages instructing harm to self or others, and giving an identity to the hallucinated voice increases the risk of compliance. A fixed delusion is a false belief held to be true despite evidence to the contrary. Magical thinking involves believing that thoughts can influence events, commonly seen in young children. Pathological regression refers to reverting to a previous developmental stage, not applicable in this scenario.

3. The primary health care provider tells a mother that her newborn has multiple visible birth defects. The mother seems composed and asks to see her baby. Which nursing action will be most helpful in easing the mother's stress when she sees her child for the first time?

Correct answer: C

Rationale: Allowing the mother time to verbalize her feelings and providing support when she sees her newborn with birth defects for the first time is crucial. Staying with her allows for immediate emotional support, acceptance, and understanding, which can help ease her stress. Bringing the infant as requested without proper emotional support may overwhelm the mother. Describing the infant's appearance before she sees the baby might not be accurate and could add to her distress. Showing pictures of the birth defects before the mother sees her baby may not be helpful and could increase her anxiety. Engaging in discussions about treatment at this point may be premature and overwhelming for the mother.

4. A female adolescent has anorexia nervosa and is malnourished and severely underweight. Which statement indicates that she is experiencing secondary gains from her behavior?

Correct answer: C

Rationale: The statement "My mother keeps trying to get me to eat" indicates that the adolescent is experiencing secondary gains from her behavior. This is because the behavior has garnered attention from her mother, providing a sense of power and control, which are considered secondary gains. The statement "I'm huge; I'm as big as a house" reflects a disturbed body perception and is not related to secondary gains. Getting straight A's in all subjects is an achievement but not a secondary gain related to anorexia nervosa. The hair falling out in clumps is a physical consequence of starvation, not a secondary gain.

5. Ten minutes after signing an operative permit for a fractured hip, an older client states, 'The aliens will be coming to get me soon!' and falls asleep. Which action should the nurse implement next?

Correct answer: B

Rationale: The client's statement about aliens coming to get them could indicate confusion, which raises concerns about their neurologic status. Since informed consent for surgery requires the client to be mentally competent, the nurse should assess the client's neurologic status to ensure they understand and can legally provide consent. Option A of making the client comfortable and letting them sleep does not address the potential neurologic issue. If the nurse finds the client to be confused, it is essential to inform the surgeon and seek permission from the next of kin if necessary. Therefore, assessing the client's neurologic status is the priority to ensure the client's ability to consent to the surgery.

Similar Questions

A client is receiving treatment for delusional behavior. He believes that his neighbor is purposefully poisoning his water system in an attempt to make him sick. Which of the following responses of the nurse is most appropriate?
The nurse plans care for a hospitalized patient who uses culturally based treatments. Which action by the nurse is best?
The mental health nurse plans to discuss a client's depression with the health care provider in the emergency department. There are two clients sitting across from the emergency department desk. Which nursing action is best?
When caring for a patient who speaks a different language and an interpreter is unavailable, which action by the nurse is most appropriate?
How is the secondary use of data from the 2000 census classification system utilized to address disparities in mental health care along racial-ethnic lines?

Access More Features

NCLEX RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

NCLEX RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

Other Courses