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: Vomiting can be a sign of a transfusion reaction, but it is not as specific as low back pain for an acute hemolytic reaction.

Choice B reason: Urticaria, or hives, may indicate an allergic reaction but is not specific to an acute hemolytic reaction.

Choice C reason: Low back pain is a classic symptom of an acute hemolytic reaction, which is a serious and potentially life-threatening condition that requires immediate attention.

Choice D reason: Pulmonary congestion may occur in various conditions and is not the most specific indicator of an acute hemolytic reaction.

A. "I should be sure the patient has no questions before they sign the consent." B. "I can witness the patient's signature on the consent." C. "Consent is good for 30 days." D. "This protects the hospital from all lawsuits."

Correct Answer is D

Explanation

Choice A reason: Ensuring the patient has no questions before signing the consent is a standard and appropriate practice.

Choice B reason: A nurse can witness the patient's signature on the consent form, which is a normal procedure.

Choice C reason: Consent is not universally good for 30 days; it is specific to the procedure and timing, and this statement could mislead and cause legal issues.

Choice D reason: Saying that informed consent protects the hospital from all lawsuits is incorrect and could lead to a false sense of security, as informed consent is about patient autonomy, not just legal protection.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client who is receiving a blood transfusion. The nurse should monitor for which of the following findings as an indication the client is having an acute hemolytic reaction?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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