A patient with schizophrenia who admits to auditory hallucinations anxiously tells the nurse, 'The voice is telling me to do things.' Which of the following responses should the nurse make next?

Correct Answer: D

Rationale: The correct answer is D: "What is the voice telling you to do?" This response helps the nurse assess the content and potential danger of the hallucinations, guiding further interventions. Option A focuses on recognition, which is less urgent. Option B addresses duration, not immediate safety. Option C inquires about fear but does not directly address the hallucination's content. By asking what the voice commands, the nurse gains crucial insight for risk assessment and safety planning.

Correct Answer: C

Rationale: The correct response is C because it focuses on exploring the underlying reasons for the patient's belief, which can help uncover any triggers or stressors leading to the delusion. This approach shows empathy, builds rapport, and encourages the patient to share more about their experiences. Choice A is dismissive and may cause the patient to feel invalidated. Choice B only focuses on the belief itself without delving deeper into the context. Choice D jumps to assumptions about the patient's emotions without addressing the core issue of the delusion. Overall, choice C promotes therapeutic communication and understanding of the patient's perspective.

Correct Answer: B

Rationale: The correct answer is B: Biological. Theories based on the brain and its activities fall under the field of biological psychology, which focuses on how biological factors influence behavior and mental processes. This includes studying brain structures, neural pathways, neurotransmitters, and their impact on behavior. Social (A) theories focus on interactions between individuals, Psychological (C) theories relate to mental processes and behavior, and Psychobiological (D) is a term that could be used interchangeably with Biological but is less commonly used. Hence, the most specific and appropriate term for theories related to the brain is Biological.

Correct Answer: B

Rationale: The correct answer is B: Delusion. A delusion is a fixed false belief that is not based on reality, such as believing one is a famous figure like the President. In this scenario, the client's belief is firmly held despite evidence to the contrary, indicating a delusion. Mutism (A) is a lack of verbal communication, not applicable here. Neologism (C) is creating new words or phrases, not seen in this example. Flight of ideas (D) is a rapid, continuous flow of speech with abrupt topic changes, which is not demonstrated in the client's behavior described.

Correct Answer: B

Rationale: The correct answer is B: Report the elder abuse and inform the patient and the daughter of your intention. This is the best intervention as it prioritizes the safety and well-being of the older adult. Here's the rationale: 1. The patient's repeated bruising and fear of disclosure indicate potential abuse. 2. Reporting elder abuse is mandatory to ensure protection for the patient. 3. Informing the patient and daughter shows transparency and involves them in the process. 4. It is crucial to address the situation promptly to prevent further harm. Summary: A: Calling the daughter may escalate the situation and compromise the patient's safety. C: Notifying the social worker without addressing the abuse directly may delay necessary action. D: Counseling may be beneficial, but addressing the abuse is a priority to ensure the patient's safety.