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 B
Explanation
Soiled dressings, which may contain infectious materials, should be disposed of in a biohazardous waste container to prevent the spread of infection.
According to standard precautions, a 1:10 bleach solution (1 part bleach to 10 parts water) is recommended for cleaning up blood spills.
Alcohol-based hand rubs are not effective against Clostridium difficile. Handwashing with soap and water is necessary to remove the spores.
Droplet precautions typically require wearing a surgical mask, not a gown and gloves. Gowns and gloves are used in contact precautions.
Correct Answer is D
Explanation
The cervical cap should be left in place for a minimum of 6 hours after intercourse but should not exceed a total of 48 hours of continuous use. Leaving it in place for longer periods may increase the risk of toxic shock syndrome (TSS) and other potential complications. Using a cervical cap in combination with a spermicide is the recommended practice for maximizing its effectiveness. Spermicide helps immobilize or kill sperm, providing an additional barrier against pregnancy when used with the cervical cap.
Using the cervical cap during the menstrual cycle is not a recommended practice for contraception. The cervical cap is primarily used during sexual activity as a barrier method of contraception and is not specifically designed for use during menstruation.
While it is important for the provider to initially fit and size the cervical cap for the client, routine checks every 6 months are not necessary. However, it is still important for the client to regularly inspect the cap for any signs of damage or deterioration and replace it as needed.
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