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During the nursing assessment, a client describes constantly hearing voices mumbling in the background. The client denies that the voices are telling him to do anything harmful. The nurse documents that the client is experiencing which of the following?
- A. Command hallucinations
- B. Auditory hallucinations
- C. Olfactory hallucinations
- D. Gustatory hallucinations
Correct Answer: B
Rationale: Hearing non-command voices indicates auditory hallucinations, the most common type in schizophrenia, distinct from command, olfactory, or gustatory hallucinations.
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One evening, a client with schizophrenia leaves his room and begins marching in the hall. When approached by the nurse, the client says, 'Goodays I'm supposed to guard the area.' Which of the following responses would be best?
- A. I understand you hear a voice. You and I are the only ones in the hall, and I don't hear a voice.
- B. The voices are part of your illness, and they will leave in time.
- C. This guarding responsibility can make you tired. You rest for now, and I'll guard a while.
- D. You are just imagining these things. Do not pay any attention to the voices.
Correct Answer: A
Rationale: Acknowledging the client's experience while presenting reality validates their perception without reinforcing the delusion, unlike dismissive or reinforcing responses.
A client diagnosed with schizophrenia is laughing and talking while sitting alone. Which of the following is the best response by the nurse?
- A. Can you share your joke with me?
- B. To sit with the client quietly until the client is ready to talk
- C. Tell me what's happening.
- D. You look lonely here. Let's join the others in the day room.
Correct Answer: C
Rationale: Asking what's happening explores the client's experience, engaging them in reality-based interaction, unlike assuming loneliness, humor, or waiting silently.
The nurse enters the room of a client with schizophrenia the day after he has been admitted to an inpatient setting and says, 'I would like to spend some time talking with you.' The client stares straight ahead and remains silent. The best response by the nurse is,
- A. I can see you want to be alone. I'll come back another time.
- B. If you don't need to talk right now, I'll just sit here for a few minutes.
- C. I've got some other things I can do now. I hope you'll feel like talking later.
- D. You would feel better if you would tell me what you're thinking.
Correct Answer: B
Rationale: Sitting quietly shows acceptance and builds trust, supporting the client's limited tolerance for interaction, unlike leaving or assuming feelings.
All of the following are nursing diagnoses identified for a client with schizophrenia. The student nurse correctly anticipates which diagnosis will resolve when the client's negative symptoms improve?
- A. Impaired verbal communication
- B. Risk for other-directed violence
- C. Disturbed thought processes
- D. Social isolation
Correct Answer: D
Rationale: Social isolation, a negative symptom, improves with negative symptom reduction, unlike impaired communication, violence risk, or thought processes, which are positive symptom-related.
The client with schizophrenia believes the student nurses are there to spy on the clients. The client is suffering from which of the following symptoms?
- A. Hallucinations
- B. Delusions
- C. Anhedonia
- D. Ideas of reference
Correct Answer: B
Rationale: Believing nurses are spying indicates delusions, fixed false beliefs, distinct from hallucinations (false perceptions), anhedonia (lack of pleasure), or ideas of reference (external events with personal meaning).