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 A

Explanation

Choice A rationale:

Checking the femoral site for hematoma formation is the most appropriate action in response to the client's complaint of pain at the right groin insertion site after a cardiac catheterization. Hematoma formation is a potential complication of this procedure and can lead to further complications if not addressed promptly. Checking for hematoma allows the nurse to assess for bleeding and take appropriate measures to manage it.

Choice B rationale:

Stimulating the client to take deep breaths is not the most immediate action needed in this situation. While deep breathing is important for respiratory function, the client's pain at the groin site requires immediate assessment to rule out complications.

Choice C rationale:

Evaluating the integrity of the IV insertion site is not the primary concern in this case. The client's pain is localized to the groin site, which is where the cardiac catheterization was performed. Checking for hematoma formation at this site takes precedence.

Choice D rationale:

Assessing distal lower extremity capillary refill is important for assessing peripheral perfusion, but it is not the most immediate action needed when a client complains of pain at a specific site, such as the right groin insertion site after a cardiac catheterization. Checking for hematoma and assessing for bleeding should come first.

A. CP is one of the most common permanent physical disabilities in children. B. Brain damage with CP is not progressive but does have a variable course. C. Severe motor dysfunction determines the extent of successful habilitation. D. Continued development of the brain lesion determines the child's outcome.

Correct Answer is B

Explanation

Choice A rationale:

Choice B rationale:

Choice C rationale:

Severe motor dysfunction determines the extent of successful habilitation is not entirely accurate. While the severity of motor dysfunction does play a role in the challenges a child with CP may face, it does not solely determine the extent of successful habilitation. Many factors, including early intervention, therapy, and individualized care, can influence a child's progress and potential for improvement.

Choice D rationale:

Continued development of the brain lesion determines the child's outcome is not an accurate statement. CP is primarily caused by non-pro

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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?

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Correct Answer is A

Explanation

The mother of a child with cerebral palsy (CP) asks the nurse if her child's impaired movements will worsen as the child grows.Which response provides the best explanation?

Correct Answer is B

Explanation

While changing a client's postoperative dressing, the nurse observes purulent drainage at the site.Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

Which statement by a mature adult client with advanced prostate cancer best indicates that he has reached a level of acceptance of his prognosis?

A nurse is providing interventions for a client with panic disorder.Which interventions should the nurse include in the plan of care? (Select all that apply).

A client with renal calculi is experiencing hematuria and reports severe flank pain.Which intervention should the nurse implement first?

The nurse requests a meal tray for a client who follows Mormon beliefs and who is on a clear liquid diet following abdominal surgery. Which menu item(s) should the nurse request for this client? (Select all that apply).

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?

On the first day after a cesarean section, a client who is a primipara is being assisted to the bathroom for the first time. The client experiences a sudden gush of vaginal blood and notices that several blood clots are in the toilet. Which action should the practical nurse (PN) take?

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?