A nurse is caring for a client in an inpatient mental health facility. The client tells the nurse that the government is reading her mail. Which of the following responses should the nurse make?
"It must be frightening to think that someone is reading your mail."
"You know that's not true, because it is against the law for others to read your mail."
"All of your letters come sealed, so that seems unlikely."
"Why do you think the government wants to read your mail?"
The Correct Answer is A
A. This response acknowledges the client's feelings and validates their experience without confirming or denying the delusion.
B. This response challenges the client's belief and may cause distress or exacerbate paranoia.
C. While factually correct, this response may not address the client's underlying concerns or feelings.
D. This response may invalidate the client's experience and may not effectively address the delusional belief.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Encouraging the client to sleep during the day disrupts the natural sleep-wake cycle and may not address the underlying issue of noise disturbances at night.
B. Minimizing conversations and activities during the nighttime promotes a quieter environment conducive to sleep, addressing the client's concern directly.
C. Using a television to cover up noise may not address the root cause of the client's sleep disturbance and could interfere with sleep hygiene.
D. Dismissing the client's concern and suggesting they will eventually get used to the noise does not address the immediate issue or offer practical solutions.
Correct Answer is D
Explanation
A. Jaundice is not a commonly reported adverse effect of citalopram. It is more commonly associated with liver dysfunction or other medications.
B. Urinary retention is not a commonly reported adverse effect of citalopram. It is more commonly associated with anticholinergic medications.
C. Bruising is not a commonly reported adverse effect of citalopram. It is more commonly associated with medications that affect platelet function or clotting factors.
D. Decreased libido (reduced sexual desire) is a potential adverse effect of citalopram, as it is with other selective serotonin reuptake inhibitors (SSRIs). Monitoring for changes in sexual function is important because it can affect quality of life and treatment adherence.
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