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?".
The Correct Answer is D
Choice A rationale:
"There is no one who will hurt you." This statement may not address the client's delusions and may be perceived as dismissive. It is important to acknowledge the client's feelings and concerns while ensuring their safety.
Choice B rationale:
"You seem quite frightened right now." This statement acknowledges the client's emotional state but does not address the specific delusion or safety concern mentioned by the client. It is essential to focus on addressing the delusional belief and ensuring safety.
Choice C rationale:
"You are in a safe place. No one can get to you here." While this statement attempts to reassure the client, it does not directly address the client's delusional belief or provide a plan for safety
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Ask the wife to stop and assess the client's swallowing reflex. Rationale: While assessing the client's swallowing reflex is important, the immediate priority is to provide hydration and comfort to the client, especially if the client is tearful and attempting to drink water. The nurse should assist the wife in providing small sips of water while being cautious and observing the client's ability to swallow safely.
Choice B rationale:
Give the wife a straw to help facilitate the client's drinking. Rationale: Giving the wife a straw may be helpful, but it does not address the client's immediate need for hydration and assistance with drinking. The nurse should actively assist in providing water to the client while assessing the client's ability to swallow safely.
Choice C rationale:
Assist the wife and carefully give the client small sips of water. Rationale: This is the correct answer. The nurse's immediate priority should be to assist the client with hydration. Providing small sips of water while being cautious and observing the client's ability to swallow safely is an appropriate action. This can help address the client's immediate needs for comfort and hydration.
Choice D rationale:
Obtain thickening powder before providing any more fluids. Rationale: While thickening powder may be necessary for clients with swallowing difficulties, it may cause unnecessary delay in providing hydration to the client in distress. The nurse should first provide water and assess the client's swallowing abilities. If thickened liquids are indicated, they can be administered later as per the healthcare provider's orders.
Correct Answer is B
Explanation
Choice A rationale:
Substituting natural fruit juices for carbonated drinks may be a beneficial dietary change, but it does not address the client's immediate issue of severe pain and inability to bear weight on the right ankle. This choice does not directly address the client's current problem and should not be the priority instruction in discharge teaching.
Choice B rationale:
Encouraging active range of motion to limit stiffness is the most appropriate instruction in this situation. The client's inability to bear weight on the right ankle after making dietary changes may be related to musculoskeletal issues or gouty arthritis. Active range of motion exercises can help prevent stiffness and improve joint function.
Choice C rationale:
Using an electric heating pad when pain is at its worst may provide some comfort, but it does not address the underlying cause of the severe pain in the right ankle. It is important to address the cause of the pain rather than relying solely on symptom management.
Choice D rationale:
Avoiding the consumption of wine, beer, and coffee may be relevant for some medical conditions, but it does not directly address the client's current problem of severe ankle pain and inability to bear weight. It is not the most immediate concern.
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