A nurse in a mental health facility is collecting a blood specimen from a client.
The client is hallucinating and states, "That looks like a snake, and I won't let it take all of my blood.”. Which of the following responses should the nurse make?.

"I'm using a syringe to obtain your blood, not a snake.”.

"Your provider requires this blood specimen.”.

"You must be mistaken.

Snakes cannot be in the clinic.”.

Answer and Explanation

The Correct Answer is D

(Null)

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Correct Answer is B

Explanation

Choice A rationale:

This statement is incorrect. Opioid withdrawal typically results in tachycardia, not bradycardia.

Choice B rationale:

This statement is correct. Diarrhea is a common symptom of opioid withdrawal.

Choice C rationale:

This statement is incorrect. Opioid withdrawal often results in restlessness and agitation, not hypokinesis.

Choice D rationale:

This statement is incorrect. Opioid withdrawal typically results in dilated pupils, not meiosis.

A. Obtain a prescription for haloperidol. B. Take the client to the seclusion room. C. Verbally de-escalate the client. D. Place the client in restraints.

Correct Answer is C

Explanation

Choice A rationale:

Obtaining a prescription for haloperidol is not the first intervention the nurse should implement. Medication should be considered only after non-pharmacological interventions have been attempted.

Choice B rationale:

Taking the client to the seclusion room is not the first intervention the nurse should implement. Seclusion should be used only as a last resort when all other interventions have failed and the client is a danger to themselves or others.

Choice C rationale:

Verbally de-escalating the client is the first intervention the nurse should implement. This involves using calm, clear communication to help the client regain control of their emotions.

Choice D rationale:

Placing the client in restraints is not the first intervention the nurse should implement. Restraints should be used only as a last resort when all other interventions have failed and the client is a danger to themselves or others.

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A nurse in a mental health facility is collecting a blood specimen from a client. The client is hallucinating and states, "That looks like a snake, and I won't let it take all of my blood.”. Which of the following responses should the nurse make?.

Nursing Test Bank

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Correct Answer is B

Explanation

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Correct Answer is C

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A nurse in a mental health facility is collecting a blood specimen from a client.
The client is hallucinating and states, "That looks like a snake, and I won't let it take all of my blood.”. Which of the following responses should the nurse make?.