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 B
Explanation
The correct answer is choice b. Respiratory alkalosis.
Choice A rationale:
Metabolic alkalosis occurs when there is a loss of acid or an increase in bicarbonate in the body. This can be due to vomiting, diuretic use, or excessive bicarbonate intake. It is not typically associated with hyperventilation.
Choice B rationale:
Respiratory alkalosis is caused by hyperventilation, which leads to a decrease in carbon dioxide (CO2) levels in the blood. This condition is often triggered by anxiety, fear, pain, or fever, all of which are present in this adolescent.
Choice C rationale:
Metabolic acidosis occurs when there is an accumulation of acid or a loss of bicarbonate in the body. This can be due to conditions like diabetic ketoacidosis, renal failure, or severe diarrhea. It is not typically associated with hyperventilation.
Choice D rationale:
Respiratory acidosis occurs when there is an accumulation of CO2 in the blood due to hypoventilation or impaired lung function. This condition is not consistent with hyperventilation, which reduces CO2 levels.
Correct Answer is ["B","D","E","F"]
Explanation
Choice A rationale:
Increased temperature alone is not a sufficient indication for pain medication in a post-pyloromyotomy infant. Fever can have various causes, and pain should be assessed based on other factors.
Choice B rationale:
Increased pulse rate can be an indication of pain in an infant following surgery like pyloromyotomy. It's important to assess the overall clinical picture and consider pain management if other signs are present.
Choice C rationale:
Increased respiratory rate alone is not a specific indicator of pain in a post-pyloromyotomy infant. Respiratory rate can vary for many reasons, so it should not be the sole criterion for pain management.
Choice D rationale:
Increased pulse rate is a potential sign of pain in a post-pyloromyotomy infant and should be considered when assessing the need for pain medication.
Choice E rationale:
Restlessness is often a sign of discomfort or pain in infants. Restlessness, along with other clinical indicators, can guide the decision to administer pain medication.
Choice F rationale:
Clenched fists can be a sign of discomfort or pain in infants, and it should be considered when assessing the need for pain management.
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