A nurse is caring for a client who has a history of alcohol use disorder and has been hospitalized for alcohol intoxication. The nurse enters the room and finds the client shouting "Get those bugs off of me." Which of the following responses should the nurse make?
"I'm sure that the bugs you see will not harm you."
"I don't see any bugs, but you seem very frightened."
"Let's get out of your room so that the bugs will not bother you
“There are no bugs in here. This is part of your illness."
The Correct Answer is B
A. "I'm sure that the bugs you see will not harm you.": This response validates the hallucination and may increase the client's anxiety.
B. "I don't see any bugs, but you seem very frightened.": This response maintains reality orientation while acknowledging the client’s emotional state, a therapeutic and non-confrontational approach.
C. "Let's get out of your room so that the bugs will not bother you": This reinforces the hallucination and may worsen disorientation.
D. “There are no bugs in here. This is part of your illness.": This is too blunt and dismissive, potentially increasing defensiveness or agitation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Liver failure:
While cocaine may affect multiple organs over time, liver failure is not a common direct effect.
B. Cardiac arrhythmias:
Cocaine causes vasoconstriction and increased sympathetic stimulation, often resulting in arrhythmias, myocardial infarction, and sudden cardiac death.
C. Lung cancer:
Not typically associated with cocaine use. More relevant to long-term tobacco or marijuana smoking.
D. Kidney damage:
While possible through rhabdomyolysis or hypertension, it's not the primary or most immediate danger.
Correct Answer is D
Explanation
A. early stage: Characterized by increasing tolerance, occasional overuse, and secretive behavior-not withdrawal symptoms.
B. middle stage: The user begins to lose control, experience guilt, and may show signs of dependence, but withdrawal is not yet severe.
C. prodromal stage: This term is not typically used in addiction staging; may be a distractor.
D. late stage: This stage involves severe physical deterioration, psychological dependence, and clear withdrawal symptoms if use is stopped.
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