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 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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is D. Activate the lockdown procedure.
Choice A rationale:
Asking the mother about expected visitors is important for later investigation, but it does not address the immediate concern of a potentially missing infant and delays necessary security measures.
Choice B rationale:
Matching ID bands is an essential step in verifying the identity of infants and mothers, but it should follow initial actions to secure the area and prevent possible abduction.
Choice C rationale:
Determining if the newborn is in the nursery is a logical step but not the first priority. The immediate action should be to secure the unit to prevent any potential abductor from leaving.
Choice D rationale:
Activating the lockdown procedure is the first priority to ensure the safety of the infant and prevent any unauthorized individuals from leaving the facility. This step is crucial to quickly address the situation and prevent potential abduction.
Correct Answer is C
Explanation
The correct answer is: C. Bronchospasm.
Metoprolol is a selective beta-1 blocker, primarily affecting the heart, but it can still have some impact on beta-2 receptors in the lungs. In clients with respiratory conditions like asthma or COPD, beta-blockers can trigger bronchospasm, leading to breathing difficulties.
Here's why the other options are less likely to be adverse effects of metoprolol:
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A. Tachycardia: Metoprolol actually lowers heart rate, so tachycardia is not a typical adverse effect. Instead, bradycardia (slow heart rate) is more common.
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B. Hyperglycemia: Beta-blockers can sometimes mask symptoms of hypoglycemia, but they don’t directly cause high blood sugar.
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D. Hyperkalemia: Metoprolol doesn’t significantly affect potassium levels, so hyperkalemia is not a common concern.
Since metoprolol is frequently used in hypertension management, nurses must monitor clients for bradycardia, hypotension, and signs of bronchospasm, especially in individuals with respiratory disorders.
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