A 70yearold client is admitted to the locked psychiatric unit, diagnosed with delirium. Later in the day, he tries to get out of the locked unit several times. He yells, "I have to leave and get to my barber. I see him every Wednesday. Let me out!"
Which of the following would be the most therapeutic response by the nurse?
"You need to come and take a shower before you can go get your hair cut."
"Please stop banging on the door. Your room is right over there."
"The door is locked so that you don't leave and get hurt."
"You are in the hospital, and I'm your nurse."
The Correct Answer is C
A. This response does not directly address the client's concern and may be perceived as dismissive.
B. This response does not provide a clear explanation for the locked door and may not effectively address the client's agitation.
C. This response provides a clear and honest explanation for the locked door, ensuring the client's safety, which is the priority.
D. This response acknowledges the situation but does not provide a clear explanation for the locked door.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B"]
Explanation
A. "I don't have a problem, I can quit when, where and how I want to." This statement reflects denial and overconfidence, which are common obstacles to recovery. It suggests a lack of recognition of the seriousness of the addiction.
B. "I am not going to let my family and friends know I have an addiction and give them this burden." This statement indicates a reluctance to seek support from loved ones, which can hinder the recovery process. Keeping the addiction, a secret can lead to isolation and make it more
challenging to maintain recovery.
C. "I will start Alcoholic Anonymous meetings in two weeks when I am settled after discharge." This statement shows proactive planning and willingness to engage in support groups, which can be a positive step towards recovery.
D. "I know I am an addict, and it will take hard work and a higher power to help me." This statement reflects self-awareness and a recognition of the effort required for recovery. The
mention of a higher power suggests a willingness to engage in a spiritual or faith based approach to recovery, which can be beneficial for some individuals.
E. "I don't know how I am going to get through this but will take it one day at a time with my family." This statement acknowledges the challenges ahead and expresses a willingness to take recovery one step at a time with the support of family. It reflects a realistic and hopeful approach to the recovery process.
Correct Answer is D
Explanation
A) Incorrect. Delusions of reference involve a belief that everyday events, objects, or other people have a particular and unusual significance. This is not described in the scenario.
B) Incorrect. Tangentiality is a thought disorder where the individual goes off on tangents and never returns to the original point or idea. This is not described in the scenario.
C) Incorrect. Neologism refers to the creation of new words or phrases that have meaning only to the person using them. This is not described in the scenario.
D) Correct. Loose associations are characterized by a disruption in the logical progression of thought, where thoughts become disorganized and may seem unrelated or loosely connected.
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