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 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.
Correct Answer is D
Explanation
Choice A reason: Bursting open of the wound is a description that could imply evisceration, but it is not as specific as choice D.
Choice B reason: Wound edges not approximating is a general description of a wound that is not healing properly, but does not specifically describe evisceration.
Choice C reason: Opening of the wound could refer to any situation where a wound has opened, not necessarily evisceration.
Choice D reason: Evisceration specifically refers to the viscera spilling out of the abdomen, usually through a surgical wound.
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