A client diagnosed with schizophrenia states, "Can't you hear him? It's the devil. He's telling me I'm going to hell." Which is the most appropriate nursing reply?

Correct Answer: C

Rationale: The correct answer is C because it acknowledges the client's experience while also providing reassurance and reality orientation. By stating that the voices sound scary and attributing them to the illness, the nurse validates the client's feelings and offers a non-judgmental response. This approach helps build trust and rapport with the client, while also providing education about the nature of their symptoms. Choice A is incorrect because it focuses solely on medication adherence without addressing the client's concerns. Choice B is incorrect because it dismisses the client's experience and offers a blanket reassurance without addressing the delusional content. Choice D is incorrect because it oversimplifies the situation and does not provide therapeutic communication or support for the client's distress.

Correct Answer: D

Rationale: The correct answer is D: Displacement. Displacement is a defense mechanism where one transfers their emotions or impulses from the original source to a less threatening target. In this scenario, the patient is redirecting their anger from their spouse to the nurse, a less threatening target. This behavior allows the patient to avoid dealing directly with the conflict. A: Denial involves refusing to accept reality. B: Projection is attributing one's own unacceptable feelings or thoughts to others. C: Sublimation is channeling unacceptable impulses into socially acceptable actions.

Correct Answer: B

Rationale: The correct answer is B: to provide comfort measures. Palliative care focuses on improving the quality of life for patients with serious illnesses by providing relief from symptoms and addressing physical, emotional, and spiritual needs. Assisted suicide (option A) is not a focus of palliative care. Aggressively treating the disease (option C) may not align with the goals of palliative care, which prioritize quality of life over aggressive treatment. Aggressively treating symptoms (option D) is important in palliative care but does not encompass the holistic approach of providing comfort measures. Overall, the priority of palliative care is to provide comfort and support to enhance the patient's well-being.

Correct Answer: D

Rationale: The correct answer is D: Hold her hand. This action best depicts the 'Caring' aspect of SENC (Support, Encourage, Nurture, and Coach). By holding her hand, you are providing physical comfort and emotional support, showing empathy and understanding. This gesture conveys a sense of presence and solidarity, helping the client feel heard and valued. Calling the parents back (A) may not be appropriate without the client's consent. Referring to the Chaplain (B) may not address the immediate emotional needs. Crying with the client (C) may blur professional boundaries and not necessarily provide the necessary support.

Correct Answer: D

Rationale: The correct answer is D: Socialization. Attending church as a family on Sundays represents a socialization function of the family. This activity helps in transmitting societal norms, values, and beliefs to the family members, promoting social integration and cohesion within the family unit. It also provides opportunities for social interaction and bonding among family members. Choices A, B, and C are incorrect because attending church does not primarily relate to physical health, economic activities, or reproduction within the family.