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 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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is A
Explanation
The correct answer is choice a. Ask the wife to stop and assess the client’s swallowing reflex.
Choice A rationale:
Assessing the client’s swallowing reflex is crucial because facial paralysis and inability to move one side can indicate a risk of aspiration. Ensuring the client can safely swallow before giving any fluids is a priority to prevent complications like aspiration pneumonia.
Choice B rationale:
Giving the wife a straw might seem helpful, but it does not address the underlying risk of aspiration. Without assessing the swallowing reflex, using a straw could still lead to aspiration.
Choice C rationale:
Assisting the wife in giving small sips of water without assessing the swallowing reflex first is unsafe. The client might not be able to swallow properly, increasing the risk of aspiration.
Choice D rationale:
Obtaining thickening powder is a good step for clients with swallowing difficulties, but it should be done after assessing the swallowing reflex. The priority is to first determine if the client can swallow safely.
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