Building Therapeutic Relationships
Building Therapeutic Relationships ( 7 Questions)
A nurse is caring for a client who has schizophrenia and is experiencing auditory hallucinations. The client tells the nurse that they hear voices telling them to harm themselves. Which of the following responses by the nurse is appropriate?
"Do you have a plan to harm yourself?" - This is an important question to ask when assessing suicide risk, but it does not address the client's hallucinations or provide any support or reassurance.
"The voices are not real and they cannot hurt you." - This is an invalidating response that contradicts the client's reality and may cause them to feel defensive or distrustful of the nurse.
"I don't hear any voices. What are they saying to you?" - This is a curious response that may reinforce the client's hallucinations or increase their anxiety.
"That must be very frightening for you. How can I help you feel safe?"
Rationale: Hallucinations are sensory perceptions that occur without external stimuli, often associated with schizophrenia. Clients who experience auditory hallucinations may hear voices that are threatening, derogatory, or commanding. The nurse should respond to the client's hallucinations with empathy, respect, and validation, while also assessing their risk for self-harm or harm to others. The nurse should also help the client cope with their hallucinations by providing distraction, reality orientation, medication administration, and environmental modification.
Correct answer: D) "That must be very frightening for you. How can I help you feel safe?"
Rationale: Hallucinations are sensory perceptions that occur without external stimuli, often associated with schizophrenia. Clients who experience auditory hallucinations may hear voices that are threatening, derogatory, or commanding. The nurse should respond to the client's hallucinations with empathy, respect, and validation, while also assessing their risk for self-harm or harm to others. The nurse should also help the client cope with their hallucinations by providing distraction, reality orientation, medication administration, and environmental modification.
Incorrect options:
A) "Do you have a plan to harm yourself?" - This is an important question to ask when assessing suicide risk, but it does not address the client's hallucinations or provide any support or reassurance.
B) "The voices are not real and they cannot hurt you." - This is an invalidating response that contradicts the client's reality and may cause them to feel defensive or distrustful of the nurse.
C) "I don't hear any voices. What are they saying to you?" - This is a curious response that may reinforce the client's hallucinations or increase their anxiety.