NCLEX National Council Licensure Examination(NCLEX-RN) NCLEX-RN Question # 217 Topic 22 Discussion
NCLEX-RN Exam Topic 22 Question 217 Discussion:
Question #: 217
Topic #: 22
A client reports to the nurse that the voices are practically nonstop and that he needs to leave the hospital immediately to find his girlfriend and kill her. The best verbal response to the client by the nurse at this time is:
A.
“I understand that the voices are real to you, but I want you to know I don’t hear them. They are a symptom of your illness.”
B.
“Just don’t pay attention to the voices. They’ll go away after some medication.”
C.
“You can’t leave here. This unit is locked and the doctor has not ordered your discharge.”
D.
“We will have to put you in seclusion and restraints for a while. You could hurt someone with thoughts like that.”
(A) This response validates the client’s experience and presents reality to him. (B) This nontherapeutic response minimizes and dismisses the client’s verbalized experience. (C) This response can be interpreted by a paranoid client as a threat, thereby increasing the client’s potential for violence and loss of control. (D) This response is also threatening. The client’s behavior does not call for restraints because he has not lost control or hurt anyone. If seclusion or restraints were indicated, the nurse should never confront the client alone.
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