A client with delusions tells the nurse, "You aren't doing your job.
Go get those people over there and shoot them before they get me." Which statement is the nurse's best response?

"There is no one who will hurt you.".

"You seem quite frightened right now.".

"You are in a safe place.No one can get to you here.".

"What would you like to see me do to protect you?".

Answer and Explanation

The Correct Answer is B

The correct answer is choice B. “You seem quite frightened right now.”.

Choice A rationale:

While reassuring the client that no one will hurt them is well-intentioned, it may not effectively address the client’s immediate emotional state or validate their feelings.

Choice B rationale:

Acknowledging the client’s fear helps validate their emotions and opens a pathway for further therapeutic communication. It shows empathy and understanding, which can help build trust and provide comfort.

Choice C rationale:

Telling the client they are in a safe place is reassuring, but it may not fully address the client’s immediate emotional distress or validate their feelings.

Choice D rationale:

Asking the client what they would like the nurse to do to protect them might reinforce the delusion and could potentially escalate the situation. It is more effective to acknowledge the client’s feelings and provide reassurance.

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Correct Answer is C

Explanation

Choice A rationale:

Nausea can be a significant factor contributing to decreased food intake, but it is not the most likely cause in this scenario. Xerostomia (dry mouth) and mucositis are mentioned as symptoms in the question stem. Nausea alone does not explain why the client is consuming less than their body requirements.

Choice B rationale:

Fatigue can also contribute to decreased food intake, but it is not the most likely cause in this case. While fatigue can be a side effect of cancer treatment and may lead to reduced appetite, the question specifically mentions xerostomia and mucositis as issues contributing to imbalanced nutritional intake.

Choice C rationale:

Pain when eating is the most likely cause of imbalanced nutritional intake in this scenario. The client's laryngeal cancer and the development of mucositis indicate that eating is likely painful for them. This discomfort can significantly deter the client from eating, leading to decreased nutritional intake.

Choice D rationale:

Altered taste sensation can affect food preferences, but it is not the most likely cause in this case. Pain when eating is a more direct and immediate barrier to food intake, especially in the context of mucositis and laryngeal cancer.

A. Whatever the parents decide, the staﬀ will be available to support the decision. B. The child's prognosis will not develop complications if surgery is delayed. C. Some children do outgrow this type of problem and waiting may be beneficial. D. Ask the parents to explain what they understand about the child's diagnosis.

Correct Answer is D

Explanation

The correct answer is choiced. Ask the parents to explain what they understand about the child’s diagnosis.

Choice A rationale:

While it is important to support the parents’ decisions, this choice does not address the need for the parents to have accurate information about the condition and its potential complications.

Choice B rationale:

This statement is incorrect.Delaying surgery for hypospadias can lead to complications such as urinary problems, infections, and issues with sexual function later in life.

Choice C rationale:

This is misleading.Hypospadias does not typically resolve on its own, and waiting can result in complications that may require more complex surgical interventions.

Choice D rationale:

This choice is correct because it encourages the parents to share their understanding of the diagnosis, allowing the nurse to provide accurate information and address any misconceptions.This approach ensures that the parents make an informed decision based on a clear understanding of the condition and its implications.

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A client with delusions tells the nurse, "You aren't doing your job. Go get those people over there and shoot them before they get me." Which statement is the nurse's best response?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who is receiving radiation treatment for laryngeal cancer has developed xerostomia and mucositis. The nurse determines the client has an imbalanced nutritional intake and is consuming less than body requirements. Which factor is the most likely cause for this problem?

Correct Answer is C

Explanation

The parents of a one-year-old child with the diagnosis of hypospadias informed the practical nurse (PN) that they plan to delay corrective surgery to see if the child will outgrow the problem. Which information should the PN provide to these parents?

Correct Answer is D

Explanation

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Which problem reported by a client taking lovastatin requires the most immediate follow-up by the nurse?

A client with delusions tells the nurse, "You aren't doing your job.
Go get those people over there and shoot them before they get me." Which statement is the nurse's best response?