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 A

Explanation

Choice A reason: A urine output of 18 mL/hr is significantly lower than the normal range (typically around 0.5-1 mL/kg/hr), indicating possible renal hypoperfusion, an early sign of shock.

Choice B reason: While blood pressure is an important indicator, it may not drop until later stages of shock.

Choice C reason: Lethargy can be a sign of shock, but it is a more subjective and later symptom compared to the objective measure of urine output.

Choice D reason: An elevated pulse is a compensatory mechanism in shock, but it is not as specific an early indicator as a decrease in urine output.

A. A rational fear of certain objects. B. Unaware of compulsions. C. Rule-conscious behavior. D. Difficulty relaxing. E. Perfectionist behavior.

Correct Answer is ["C","D","E"]

Explanation

Choice A reason: A rational fear of certain objects is not typically associated with OCD, which is characterized by irrational fears or obsessions.

Choice B reason: Clients with OCD are usually very aware of their compulsions, even if they cannot control them.

Choice C reason: Rule-conscious behavior is common in OCD, as individuals may create strict routines to manage their anxiety.

Choice D reason: Difficulty relaxing is a characteristic of OCD due to persistent intrusive thoughts and compulsive behaviors.

Choice E reason: Perfectionist behavior is often seen in OCD, where there is an excessive concern with orderliness and details.

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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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