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. 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.
Correct Answer is A
Explanation
A. Tardive dyskinesia is a movement disorder often caused by long-term use of antipsychotic medications like chlorpromazine. Symptoms include involuntary movements such as jerking or lip smacking.
B. Lock Jaw is not a characteristic of tardive dyskinesia; it refers to trismus, often seen with other conditions.
C. Pseudoparkinsonism is characterized by tremors, rigidity, and bradykinesia, typically occurring early in antipsychotic treatment.
D. Akathisia involves restlessness and an inability to stay still, not the involuntary movements associated with tardive dyskinesia.
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