A nurse is caring for a client who has delusional behavior. The client states, "I can't go to group today. I am expecting a high level official to visit me!" Which of the following responses should the nurse make?
"Let's walk together to group so we can discuss your concerns."
"I think you should attend group therapy. We will talk about this when you're done."
"I wouldn't worry about that. They will call you back later."
"Why do you think you are getting a visit from someone today?"
The Correct Answer is A
A. Acknowledge the client’s delusion while gently redirecting them to the necessary activity (group
therapy). This approach maintains engagement without directly confronting the delusion.
B. Ignoring the delusion and focusing only on group therapy may cause the client to feel unheard or dismissed.
C. Dismissing the delusion is not therapeutic and could undermine trust.
D. Asking "why" could challenge the delusion, leading to defensiveness rather than productive conversation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The nurse’s primary concern is preventing the client from embarrassing herself due to the impulsive and disinhibited behaviors typical of a manic episode.
B. There is no indication that dancing is prohibited; the issue is with inappropriate behavior.
C. The focus of the action is not on sexual behavior but on ensuring the client is appropriately dressed in a social setting.
D. Following policy is important, but the nurse’s action is more about protecting the client from social
embarrassment.
Correct Answer is ["2.5"]
Explanation
To determine how many tablets to administer, divide the prescribed dose by the available dose per tablet:
25mg/10 mg/tablet = 2.5
Tablets 10mg/tablet 25mg =2.5tablets
Thus, the nurse should administer 2.5 tablets of buspirone.
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