27 31 st louis mosby varcarolis e halter m 2009

27-31). St. Louis: Mosby.
Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing: A
communication approach to evidence-based care (p. 480). St. Louis: Saunders.
Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Communication and Documentation
Content Area: Mental Health
Giddens Concepts: Cognition, Clinical Judgment
HESI Concepts: Clinical Decision-Making/Clinical Judgment
22.ID: 9476891495
A schizophrenic client is seen seemingly talking to someone who isn’t there. Which
nursing statement would be most therapeutic initially ?
· “You need to wash up and get ready to go to supper in the cafeteria with the other
clients now.”
· “I’ve noticed your eyes darting back and forth, and I wondered whether you might
be hearing voices.” Correct
· “You were telling me yesterday that your mother died last June of cancer. Can you
tell me more about that?”
· “Today is my birthday. Would you like to go on an outing with my family?”
Rationale: The most therapeutic nursing statement is the one in which the nurse
addresses the client’s behavior and asks whether the client is hearing voices. With this
statement, the nurse also assesses the client’s behavior. If the client is hearing voices, the
nurse prevents reinforcement of the hallucinatory thinking by telling the client that he or
she does not hear them. In asking, “Today is my birthday. Would you like to go on an
outing with my family?” the nurse nontherapeutically changes the focus from the client.
In stating, “You need to wash up and get ready to go to supper in the cafeteria with the
other clients now,” the nurse ignores the client’s obvious psychotic behavior and directs
the client to socialize with others. Such an intervention is not usually positive, because it
floods the client with stimuli that may contribute to an escalation of psychotic behavior.
In asking, “You were telling me yesterday that your mother died last June of cancer. Can
you tell me more about that?” the nurse uses distraction, summarization, and refocusing.
Test-Taking Strategy: Note the strategic words “most” and “initially” and eliminate the
options that are unrelated to the client’s behavior. Also, focus on the data in the question.
The correct option is the only one that addresses the client’s behavior. Review: care of the
client who is hallucinating .
Reference: Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health
nursing: A communication approach to evidence-based care (pp. 287, 288). St. Louis:
Saunders.
Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Communication and Documentation
Content Area: Mental Health
Giddens Concepts: Communication, Psychosis

HESI Concepts: Cognition—Psychosis, Communication
Awarded 1.0 points out of 1.0 possible points.