A middle-aged female client with no previous psychiatric history is seen in the mental health clinic because her family describes her as having paranoid thoughts. On assessment, she tells the nurse, "I want to find out why these people are stalking me!" Which response should the nurse provide?
"Do you think someone is trying to harm you?"
"What makes you think people are stalking you?"
"It sounds like this experience is frightening for you."
"I know you are frightened, but no one is stalking you."
The Correct Answer is B
Choice A rationale: "Do you think someone is trying to harm you?" is a leading question and may contribute to the client's paranoid thoughts. It is important to explore the client's concerns without making assumptions.
Choice B rationale: "What makes you think people are stalking you?" is an open-ended question that invites the client to share more about her experiences and thought processes. It allows for a deeper exploration of the client's perceptions.
Choice C rationale: "It sounds like this experience is frightening for you" is a closed statement and may not encourage the client to elaborate on her thoughts. Open-ended questions are more effective in this situation.
Choice D rationale: "I know you are frightened, but no one is stalking you" is a dismissive statement that may invalidate the client's feelings. It is imp
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale: Administering an antianxiolytic medication may be appropriate, but addressing the client's fluid and electrolyte imbalance is the priority.
Choice B rationale: Inserting a fecal management tube is not the first action to take in response to hemoccult positive liquid stools; addressing fluid balance is more urgent.
Choice C rationale: Inserting a peripheral intravenous catheter is the priority to address the client's fluid and electrolyte imbalance and provide necessary hydration and medications.
Choice D rationale: Crushing pills and placing them in applesauce may be considered, but the client's fluid and electrolyte imbalance needs prompt attention first.
Correct Answer is C
Explanation
Choice A rationale: Self-control is not the primary issue identified in this scenario. The client's self-blame may be related to other factors.
Choice B rationale: Self-actualization is not the primary issue in this scenario. The client is dealing with feelings of self-blame and potential guilt.
Choice C rationale: Self-esteem is the most relevant issue in this scenario. The client expresses feelings of self-blame, indicating a potential impact on self-esteem. Addressing self-esteem is crucial for the client's emotional well-being.
Choice D rationale: Self-absorption is not the primary issue in this scenario. The client's focus on self-blame and guilt is related to self-esteem concerns.
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