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?".
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:
Encouraging the client to face their fear gradually is an appropriate nursing intervention for a client with a phobia. This approach is consistent with exposure therapy, which is a widely recognized and effective treatment for phobias. Exposure therapy involves gradually exposing the client to the feared object or situation in a controlled and supportive environment. By doing so, the client can learn to confront and manage their fear over time. This approach is evidence-based and helps the client build resilience and reduce anxiety.
Choice B rationale:
Administering benzodiazepines as needed for acute anxiety (Choice B) is not the first-line treatment for phobias. While benzodiazepines can provide temporary relief from anxiety symptoms, they do not address the underlying phobia and can lead to dependence and tolerance with prolonged use. Moreover, they are generally reserved for acute anxiety episodes and not considered a primary treatment for phobias.
Choice C rationale:
Providing psychoeducation about the causes and effects of phobias (Choice C) is a valuable component of treatment, but it alone may not be sufficient. Psychoeducation can help clients understand the nature of their phobia and reduce stigma, but it should be combined with evidence-based therapies like exposure therapy for comprehensive care.
Choice D rationale:
Teaching the client relaxation techniques to manage anxiety (Choice D) can be a helpful adjunct to treatment, but it is not the primary intervention for phobias. Relaxation techniques can be part of a broader strategy to reduce anxiety, but the client also needs exposure therapy or cognitive-behavioral therapy to address the phobia directly.
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale:
Slower reaction time is a common age-related change in the neurological system. The processing of sensory information and response time may become slower in older adults due to changes in neural pathways and decreased neurotransmitter activity.
Choice B rationale:
Older adults may experience some difficulty with learning new things due to changes in cognitive function and neural plasticity. This is a common age-related effect on the neurological system.
Choice C rationale:
This statement is incorrect. Older adults typically have fewer neurotransmitters in their brains as they age, which can contribute to cognitive changes and a decline in cognitive function.
Choice D rationale:
Loss of some sense of smell and taste is an age-related change. Older adults may experience a decreased ability to detect and differentiate smells and tastes due to changes in olfactory and gustatory receptors.
Choice E rationale:
This statement is incorrect. Aging does not necessarily lead to an increase in oxygen delivery to brain cells. In fact, there may be a decrease in cerebral blood flow with age in some individuals.
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