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 C

Explanation

The correct answer is c. Recommend using a breast shield.

Choice A reason: Offering supplemental formula feedings is not the first-line action for inverted nipples as it does not address the issue and may lead to nipple confusion, potentially complicating future breastfeeding attempts.

Choice B reason: Teaching about the use of a breast pump is beneficial for milk expression but does not directly assist with the immediate concern of latching issues due to inverted nipples.

Choice C reason: Using a breast shield can be helpful for mothers with inverted nipples. It can temporarily draw out the nipple, allowing the baby to latch on more easily. This tool acts as a bridge between the breast and the baby's mouth, facilitating breastfeeding while the mother works on long-term solutions for her inverted nipples.

Choice D reason: Encouraging the use of ice on the areola may temporarily stiffen the nipple, but it is not a recommended practice for addressing inverted nipples as it can cause discomfort and may not be effective in promoting a successful latch.

A. Add lentils and black beans to soups B. Eat red meat just until the anemia is resolved C. Take two prenatal vitamins with iron daily D. Oatmeal is a good choice for breakfast E. Increase green leafy vegetables in the diet

Correct Answer is ["A","D","E"]

Explanation

Since the pregnant woman is vegetarian and does not eat meat, the practical nurse (PN) should provide alternative sources of iron-rich foods. Lentils and black beans are excellent vegetarian sources of iron and can be added to soups to increase iron intake (option a).

Oatmeal is a good choice for breakfast as it is often fortified with iron (option d). This can help supplement

iron intake in the diet.

Green leafy vegetables, such as spinach, kale, and broccoli, are also rich in iron and should be increased in the client's diet (option e).

Option b, which suggests eating red meat just until the anemia is resolved, is not appropriate for a vegetarian client.

Option c, taking two prenatal vitamins with iron daily, is not necessary unless specifically advised by the healthcare provider. It is important to follow the prescribed dosage of medication and supplements as directed by the healthcare provider.

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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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Naxlex Comprehensive Predictor Exams

A client who is one day postpartum reports to the nurse that her baby cannot latch onto the breast. The nurse observes that the client's nipples are inverted. Which action should the nurse implement?

Correct Answer is C

Explanation

Correct Answer is ["A","D","E"]

Explanation

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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?