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 A
Explanation
Choice A reason: This question assesses abstract thinking and judgment by asking the client to consider a hypothetical situation and propose a solution.
Choice B reason: Asking about the city of birth is a fact-based question and does not assess abstract thinking or judgment.
Choice C reason: Inquiring about breakfast is a recall question and does not evaluate abstract thinking or judgment.
Choice D reason: Asking who the president is tests knowledge of current events, not abstract thinking or judgment.
Correct Answer is D
Explanation
Choice A reason: A sodium level of 138 milliequivalents per liter is within the normal range and does not indicate metastasis.
Choice B reason: A hemoglobin level of 10.5 grams per deciliter is slightly low but does not specifically indicate metastasis.
Choice C reason: A potassium level of 3.4 milliequivalents per liter is within the normal range and does not indicate metastasis.
Choice D reason: A calcium level of 12.5 milligrams per deciliter is elevated, which may indicate metastasis to the bones, a common site for breast cancer metastasis.
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