A nurse is caring for a client who has schizophrenia. The client states, "They lie about me all the time and are trying to poison my food." Which of the following responses should the nurse make?

"You seem to be having some very frightening thoughts."

"Why do you think you are being lied about and poisoned?"

"You are mistaken. Nobody is lying about you or trying to poison you."

"Who is lying about you and trying to poison you?"

Answer and Explanation

The Correct Answer is A

Choice A reason: This response acknowledges the client's feelings without agreeing with the delusion or challenging their reality, which can help in building trust and rapport.

Choice B reason: Asking "Why do you think you are being lied about and poisoned?" could potentially reinforce the delusion and lead the client to further justify their beliefs.

Choice C reason: Directly telling the client they are mistaken can be confrontational and may damage the therapeutic relationship.

Choice D reason: Asking "Who is lying about you and trying to poison you?" can validate the delusion and is not a therapeutic response.

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Correct Answer is C

Explanation

Choice A reason: Borderline personality disorder is characterized by instability in relationships, self-image, and emotions, not necessarily by being pouty and demanding attention.

Choice B reason: Schizoid personality disorder involves detachment from social relationships and a limited range of emotional expression, which does not align with the patient's behavior.

Choice C reason: Narcissistic personality disorder includes traits such as needing excessive admiration and having a sense of entitlement, which could explain the patient's behavior.

Choice D reason: Antisocial personality disorder is marked by a disregard for and violation of the rights of others, which is not described in the patient's behavior.

A. Provide ordered enteral nutrition. B. Monitor ordered IV fluids. C. Obtain blood cultures before antibiotics. D. Give broad-spectrum antibiotics within one hour of septic shock diagnosis.

Correct Answer is D

Explanation

Choice A reason: While nutrition is important, it is not the immediate priority in the management of septic shock.

Choice B reason: Monitoring IV fluids is important, but the initial priority is to treat the infection causing the septic shock.

Choice C reason: Obtaining blood cultures is important, but it should not delay the administration of antibiotics.

Choice D reason: The administration of broad-spectrum antibiotics within one hour of diagnosing septic shock is critical to improve outcomes and is considered a priority action.

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A nurse is caring for a client who has schizophrenia. The client states, "They lie about me all the time and are trying to poison my food." Which of the following responses should the nurse make?

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Correct Answer is C

Explanation

Which of these would the nurse implement as the priority action for the patient with newly diagnosed septic shock?

Correct Answer is D

Explanation

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