Author Question: A patient diagnosed with schizophrenia anxiously says, I can see the left side of my body merging ... (Read 27 times)

jon_i · **on:** Jul 19, 2018

A patient diagnosed with schizophrenia anxiously says, I can see the left side of my body merging with the wall, then my face appears and disappears in the mirror. While listening, the nurse should:

a. sit close to the patient.
b. place an arm protectively around the patient's shoulders.
c. place a hand on the patient's arm and exert light pressure.
d. maintain a normal social interaction distance from the patient.

Question 2

A patient diagnosed with schizophrenia and auditory hallucinations anxiously tells the nurse, The voice is telling me to do things. Select the nurse's priority assessment question.

a. How long has the voice been directing your behavior?
b. Does what the voice tell you to do frighten you?
c. Do you recognize the voice speaking to you?'
d. What is the voice telling you to do?

morrie123456 · **Reply #1 on:** Jul 19, 2018

Answer to Question 1

ANS: D
The patient is describing phenomena that indicate personal boundary difficulties and depersonalization. The nurse should maintain appropriate social distance and not touch the patient because the patient is anxious about the inability to maintain ego boundaries and merging or being swallowed by the environment. Physical closeness or touch could precipitate panic.

Answer to Question 2

ANS: D
Learning what a command hallucination is telling the patient to do is important because the command often places the patient or others at risk for harm. Command hallucinations can be terrifying and may pose a psychiatric emergency. The incorrect questions are of lesser importance than identifying the command.