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.

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

Answer and Explanation

The Correct Answer is B

The correct answer is B. "You seem quite frightened right now."

Choice A rationale:

This statement dismisses the client's feelings and may not provide the reassurance they need. It could also escalate the situation if the client feels misunderstood or ignored.

Choice B rationale:

This response acknowledges the client's emotions and validates their experience, which can help build trust and de-escalate the situation. It shows empathy and understanding, which are crucial in managing delusions.

Choice C rationale:

While this statement aims to reassure the client, it may not address their immediate emotional state. The client might not feel safe despite being told they are, so it might not be as effective in calming them down.

Choice D rationale:

This response could inadvertently reinforce the client's delusions by implying that their fears are valid and that the nurse should take action based on those delusions. It might also confuse the client further.

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Correct Answer is C

Explanation

Choice A rationale:

Ketonuria is not a common complication of diabetes insipidus. Ketonuria is associated with diabetes mellitus, a different condition that results in the accumulation of ketones in the urine due to insufficient insulin.

Choice B rationale:

Peripheral edema is also an unlikely complication of diabetes insipidus. Diabetes insipidus is characterized by excessive thirst and urination, not fluid retention or peripheral edema.

A. Avocados and cheese. B. Fresh fruits. C. Yogurt or buttermilk. D. Green leafy vegetables.

Correct Answer is C

Explanation

Choice A rationale:

Avocados and cheese are not specifically recommended for a client with a postoperative wound infection. While a balanced diet is important for overall health, yogurt or buttermilk is a better choice due to their probiotic content, which may promote gut health and support the immune system.

Choice B rationale:

Fresh fruits are generally a healthy dietary choice, but they are not particularly relevant to the management of a postoperative wound infection. The emphasis for this client should be on foods that support wound healing and immune function, such as yogurt or buttermilk.

Choice D rationale:

Green leafy vegetables are rich in vitamins and minerals, but they are not a primary focus for a client with a postoperative wound infection. Again, the emphasis should be on foods that support the immune system and overall recovery, such as yogurt or buttermilk.

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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 is admitted to the intensive care unit with diabetes insipidus due to a pituitary gland tumor.Which potential complication should the nurse monitor closely?

Correct Answer is C

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The healthcare provider prescribes the antibiotic cefdinir 300 mg by mouth every 12 hours for a client with a postoperative wound infection.Which foods should the nurse encourage this client to eat?

Correct Answer is C

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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?