A client previously diagnosed as psychotic expresses to the nurse ...

[burchfield96]

A client previously diagnosed as psychotic expresses to the nurse that he is seeing spiders climbing up the walls in his room and he is concerned that they will get into his bed. What is the nurse's best response?
 
  a. Ignore his remarks and remain silent when providing care.
  b. Express doubt that there are spiders on the wall.
  c. Ask the client if he also sees spiders in the day room.
  d. Tell the client there are no spiders and he should stop worrying about it.

Question 2

A client with schizophrenia has relapsed and has been identified as being in stage four of relapse. The nurse expects to observe which behavior that most consistent with this stage of relapse?
 
  a. Expressing feelings of anxiety
  b. Expressing feelings of being overwhelmed
  c. Bizarre behaviors and speech
  d. Presence of hallucinations

[lkanara2]

Answer to Question 1

ANS: B
The client is experiencing visual hallucinations. Appropriate care for this client would not include reinforcing his hallucinations, being dismissive of him, or ignoring him. Expressing reasonable doubt is the correct answer.

Answer to Question 2

ANS: D
Schizophrenic clients who relapse go through five stages. Correctly identifying which stage the relapsing client is in is important so that interventions can be specific to the behavior. Expressing feelings of anxiety would be part of stage two, expressing feelings of being overwhelmed would be part of stage one, and bizarre behaviors and speech would be part of stage three. Presence of hallucinations is consistent with stage four, psychotic disorganization.