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?"

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. While crying may be a normal expression of grief, determining the client’s stage of grief is more important for assessing the client’s emotional needs.
B. Determining the client’s stage of grief is the first step to understanding the client's emotional state
and providing appropriate support.
C. Encouraging expression is important, but first, understanding the client’s grief stage will guide the
intervention.
D. Spiritual support is valuable, but first, understanding the client's emotional response is necessary before offering this type of assistance.

A. pulse deficit B. diastolic C. auscultatory gap D. widened pulse pressure

Correct Answer is C

Explanation

A. A pulse deficit refers to a condition where there is a difference between the radial and apical pulse rates, not a phenomenon heard during blood pressure measurement.
B. Diastolic pressure is the point at which sounds fade away or become muffled, but the silence between sounds refers to a different concept, not the actual diastolic pressure.
C. An auscultatory gap is the term used to describe a silent interval between the systolic and diastolic sounds during blood pressure measurement. This can lead to inaccurately low readings if not identified.
D. A widened pulse pressure refers to a larger-than-normal difference between systolic and diastolic pressure, which is not related to the auscultatory silence.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has major depressive disorder and has experienced a recent loss. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

If a silence is heard between sounds when auscultating blood pressure, it is termed a(n)

Correct Answer is C

Explanation

A nurse is making a home visit for a 16-year-old adolescent who attempted suicide. Which of the following behaviors should alert the nurse that the adolescent still has suicidal intent?

A nurse is collecting data from a client who has bipolar disorder with mania. Which of the following findings is the nurse's priority?

A nurse is collecting data from a client who has schizophrenia and has been taking chlorpromazine for 8 years. The nurse notes choreiform or jerking uncontrolled movements, lip smacking, and spastic facial distortions. Which of the following conditions should the nurse document in her finding?

A nurse is collecting data on a client and finds that Ari is always manic but has had one depressive episode in the last year. Which of the following diagnosis should the nurse suspect?

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A nurse is discussing quality of life with a client who has schizophrenia. Which of the following statements should the nurse include?

The nurse is teaching the family of a client about the signs and symptoms of major depression prior to the discharge of their loved one from an inpatient stay after a suicide attempt. Which statement by a family member warrants further education by the nurse?