A nurse is caring for a client who has paranoid schizophrenia and believes that they are being followed by FBI agents who are pretending to be psychiatric staff.
Which of the following responses should the nurse make?
The psychiatric staff is not FBI. They are here to help you.
This must be very frightening for you. Let's talk more about it.
What makes you think the staff is following you?
Why do you feel the staff is the FBI?
The Correct Answer is B
b. This must be very frightening for you. Let's talk more about it.
It is important for the nurse to acknowledge the client's fears and show empathy towards them. By saying "This must be very frightening for you," the nurse validates the client's feelings and shows that they are being heard.
Additionally, by suggesting that they talk more about it, the nurse can work towards building a therapeutic relationship with the client and gain more insight into their thought processes.
The other options are not appropriate because:
a. The nurse should not deny the client's beliefs or try to convince them that they are wrong. This can cause
the client to feel invalidated and may make them less likely to trust the nurse.
c. While it is important to understand the client's perspective, this question may come off as confrontational and accusatory.
d. Similarly, this question may be perceived as confrontational and may make the client defensive. It is important to approach the client with empathy and understanding rather than skepticism.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is: a. Temperature 38.8° C (101.8° F)
Title: Choice A reason: A temperature of 38.8° C (101.8° F) is indicative of a fever, which is a common symptom of a hemolytic transfusion reaction. During such a reaction, the immune system attacks the transfused red blood cells, leading to their destruction and the release of substances that can cause a rise in body temperature.
Title: Choice B reason: Straw-colored urine is not typically associated with a hemolytic transfusion reaction. Hemolytic reactions often result in darker urine due to the presence of free hemoglobin released from destroyed red blood cells.
Title: Choice C reason: An apical pulse rate of 58/min is considered bradycardia if it is lower than the normal resting heart rate for adults, which ranges from 60 to 100 beats per minute. Bradycardia is not a direct indicator of a hemolytic transfusion reaction.
Title: Choice D reason: Elevated blood pressure, such as 158/92 mm Hg, can be a sign of various conditions but is not a specific indicator of a hemolytic transfusion reaction. The symptoms of such a reaction are more directly related to the destruction of red blood cells and the body’s response to it.
Correct Answer is ["B","C"]
Explanation
Turn cellular phones to silent mode: In an active shooter situation, it is crucial to maintain silence to avoid drawing attention to your location. Switching cellular phones to silent mode helps ensure that ringtones or notifications do not alert the shooter to your presence.
Wave hands to attract the attention of law enforcement: When law enforcement or emergency personnel arrive at the scene, it is essential to signal to them that you are not a threat and that you require assistance. This can be done by putting hands up, keeping them visible, and following any instructions provided by law enforcement.
Move wounded clients to a safe area before finding shelter: It is important to prioritize the safety of individuals involved in an active shooter situation. However, moving wounded clients should be done only if it can be done quickly and without putting oneself or others at risk. The primary goal is to seek safety and follow established protocols, such as "run, hide, fight" principles, rather than focusing on moving injured individuals during an ongoing threat.
Attempt to bargain with the shooter: Bargaining or negotiating with an active shooter is strongly discouraged. It is important to remember that the primary goal in an active shooter situation is to ensure personal safety and the safety of others. Engaging with the shooter may escalate the situation or put oneself and others at greater risk.
The in-service should focus on providing staff members with practical guidance on how to respond to an active shooter situation, emphasizing the importance of following established protocols, staying calm, and seeking safety. Additionally, the in-service should include training on recognizing and reporting suspicious behavior, as prevention and early intervention can play a crucial role in mitigating such incidents.
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