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?"
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E","F"]
Explanation
Choice A reason: LPNs are involved in developing the patient's plan of care by gathering data and collaborating with the RN to ensure the plan is tailored to the patient's needs.
Choice B reason: Providing informed consent is typically the responsibility of the physician or advanced practice nurses, not the LPN.
Choice C reason: LPNs provide emotional support to patients, helping to alleviate anxiety and offering comfort before the surgery.
Choice D reason: LPNs assist with data collection, such as gathering vital signs and medical history, which is crucial for the preoperative assessment.
Choice E reason: Including families in preoperative care is part of the holistic approach to nursing, where LPNs can provide information and support to the patient's family.
Choice F reason: LPNs reinforce patient teaching by reviewing instructions and care plans with the patient and their family to ensure understanding and compliance.
Correct Answer is ["B","C","D","E","F"]
Explanation
Choice A reason: Telling the patient everything will be okay is not an appropriate intervention as it does not address the specific educational needs related to their knowledge deficit.
Choice B reason: Including family members in teaching can provide additional support and help reinforce the information provided to the patient.
Choice C reason: Identifying knowledge deficiencies is essential to tailor the education to the patient's specific needs.
Choice D reason: Providing written and verbal materials can help the patient understand and remember the information about their surgery and care.
Choice E reason: Determining the patient's anxiety levels can help the nurse address any concerns or fears that may affect their learning.
Choice F reason: Documenting patient understanding and teaching provided is important for continuity of care and to ensure that the patient has received and understood the necessary information.
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