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?

 

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.

Choice A rationale:

Emphasize that using safe sex practices removes the risk of STIs. Rationale: While promoting safe sex practices is essential in preventing STIs, this response is not directly addressing the client's situation. The client already reports having unprotected sex, so this choice does not provide relevant information or address the potential consequences.

Choice B rationale:

Explain that reinfections occur from sex with untreated partners. Rationale: This is the correct response. Syphilis is a sexually transmitted infection that can be treated with antibiotics, but reinfections can occur if sexual partners are not treated. This response provides essential information about the potential consequences of unprotected sex with untreated partners.

Choice C rationale:

Clarify that all STIs are transmitted through sexual intercourse. Rationale: While this statement is accurate in a general sense, it does not specifically address the client's situation or the risks associated with syphilis. It lacks the focus needed to educate the client effectively about their current situation.

Choice D rationale:

Provide counseling that most contraceptives protect against infection. Rationale: This response is inaccurate. Contraceptives primarily aim to prevent pregnancy, not protect against STIs. Therefore, it does not address the client's concern or provide relevant information about syphilis.