A client experiencing mania is scheduled for a chest x-ray. Before taking the client to the radiology department the nurse should:
Cancel the appointment until the patient can go unescorted
Explain the procedure in simple terms
Give a thorough explanation of the procedure
Call security to be on standby for possible behavior problems
The Correct Answer is B
Choice A reason: Canceling the appointment delays necessary care and is not appropriate unless safety cannot be managed.
Choice B reason: Clients experiencing mania have short attention spans and difficulty processing complex information. Explaining the procedure in simple, clear terms is the most effective approach.
Choice C reason: A thorough explanation may overwhelm the client and increase agitation due to their inability to focus.
Choice D reason: Calling security preemptively is unnecessary unless there is a history of violence. It may escalate the situation and increase paranoia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Promising secrecy is inappropriate because nurses are mandated reporters. They are legally and ethically obligated to report suspected child abuse. Making such a promise undermines trust when disclosure becomes necessary.
Choice B reason: Labeling the family as "bad" is judgmental and non-therapeutic. It risks alienating the child and does not provide supportive reassurance.
Choice C reason: Telling the child that it is not their fault is therapeutic and supportive. Children often internalize blame for abuse, so this statement helps reduce guilt and shame while validating their experience.
Choice D reason: Discussing the abuse directly with family members can place the child at further risk and is inappropriate. The nurse must follow mandated reporting procedures rather than confronting the family.
Correct Answer is A
Explanation
Choice A reason: Encouraging focus on reality-based issues helps redirect the client gently without reinforcing delusions. It maintains therapeutic communication while grounding the client.
Choice B reason: Asking for meaning focuses attention on the delusion, reinforcing it rather than redirecting.
Choice C reason: Persuading the client that thoughts are not true is confrontational and ineffective. Clients with schizophrenia may not accept reality testing when actively delusional.
Choice D reason: Allowing continued delusional talk reinforces psychosis and does not promote reality orientation.
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