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 B
Explanation
Choice A rationale: Demonstrates thought-blocking is incorrect. Thought-blocking involves a sudden interruption in the client's speech, whereas the client in this scenario is experiencing racing thoughts.
Choice B rationale: Exhibits tangential thinking is the correct description. Tangential thinking involves presenting numerous ideas that are loosely or not at all connected. The client's statements reflect tangential thinking as she jumps from one idea to another without clear connections.
Choice C rationale: Displays the use of word salad is incorrect. Word salad refers to a mix of words and phrases that lack coherence and do not form a meaningful statement. The client's statements, though rapid, are connected and form a series of thoughts. Choice D rationale: Uses incoherent speech is incorrect. Incoherent speech implies a lack of clarity and organization in the client's verbal expression. The client's statements, while fast-paced, maintain coherence and are comprehensible.
Correct Answer is ["A","C","D"]
Explanation
Choice A rationale: Giving concise and firm directions for hygiene and dressing helps provide structure and support during periods of manic behavior.
Choice B rationale: Engaging the client in competitive activities may exacerbate manic symptoms, so it is not the best approach.
Choice C rationale: Assigning the client to a single room provides a quieter and less stimulating environment, promoting a more controlled and therapeutic setting. Choice D rationale: Inviting the client for a walk when their energy is high allows for a structured outlet for excess energy and may help with symptom management.
Choice E rationale: Providing television programs with suspense may contribute to overstimulation and is not the best approach during manic episodes.
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