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?

 

Choice A rationale:

"Phobias are characterized by persistent and irrational fear" (Choice A) is an accurate statement. Phobias are defined by the presence of an intense and irrational fear of a specific object or situation. This fear is persistent and often leads to avoidance behaviors, which can significantly impact the individual's daily life.

Choice B rationale:

"Phobias can be caused by biological factors only" (Choice B) is an inaccurate statement. Phobias can have various causes, including both biological and psychological factors. While there may be genetic predispositions to certain phobias, psychological factors, such as traumatic experiences or learned behaviors, can also contribute to the development of phobias.

Choice C rationale:

"Phobias can be diagnosed based on physical symptoms" (Choice C) is an inaccurate statement. Phobias are typically diagnosed based on the individual's reported symptoms, such as intense fear and avoidance behaviors. There are no specific physical symptoms that directly indicate the presence of a phobia.

Choice D rationale:

"Phobias can be managed with medication alone" (Choice D) is an inaccurate statement. Medication alone is not considered the primary treatment for phobias. While medications like selective serotonin reuptake inhibitors (SSRIs) or benzodiazepines may be prescribed to alleviate anxiety symptoms, the most effective treatment for phobias is psychotherapy, particularly exposure therapy or cognitive-behavioral therapy. These therapies address the root causes of the phobia and help individuals learn to manage their fear.

Based on the collected data, the nurse recognizes that the client is most likely exhibiting signs of Stroke as evidenced by Neurological defects and Garbled speech. The symptoms of facial drooping, garbled speech, and high blood pressure are common signs of a stroke. However, it’s important to get a professional medical diagnosis as soon as possible. Please seek immediate medical attention.

Choice A rationale:

Intoxication is a plausible explanation for the client’s symptoms, especially given the report of alcohol consumption. However, intoxication typically does not cause facial drooping, which is a common sign of neurological issues such as a stroke. Therefore, while intoxication may contribute to the client’s condition, it is not the most likely primary cause.

Choice B rationale:

Stroke is a medical emergency that often presents with facial drooping and garbled speech, both of which are observed in this client. A stroke occurs when blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients. This can lead to brain cells dying in minutes. The client’s high blood pressure (210/98 mm Hg) is a significant risk factor for stroke. Normal blood pressure ranges from 90/60 mm Hg to 120/80 mm Hg.

Choice C rationale:

An allergic reaction could cause various symptoms, but it typically does not result in facial drooping or garbled speech. Common signs of an allergic reaction include hives, itching, redness, and swelling of the skin, as well as difficulty breathing in severe cases (anaphylaxis). There is no mention of these symptoms in the client’s presentation.

Choice D rationale:

Malignant hypertension is a possibility given the client’s extremely high blood pressure reading. This condition refers to severe hypertension that can quickly lead to organ damage. However, while it can cause neurological symptoms if it leads to a hypertensive crisis, the specific symptoms of facial drooping and garbled speech are more indicative of a stroke. In conclusion, based on the collected data, the nurse recognizes that the client is most likely exhibiting signs of a stroke as evidenced by neurological defects (facial drooping and garbled speech). The client’s high blood pressure and reported alcohol consumption are both risk factors for stroke. Immediate medical intervention is crucial to minimize brain damage and potential complications.