A nurse is caring for a client who has schizophrenia. The client tells the nurse, "Government agents are out to get me." Which of the following responses should the nurse make?
"You will be okay."
"Feelings of persecution are normal with your condition."
"It must be frightening to believe that someone is after you."
"Let me check to see if it's time to take your medication."
The Correct Answer is C
A. Incorrect. This response dismisses the client's concerns and does not acknowledge the distress the client may be experiencing.
B. Incorrect. While it's true that paranoia is a common symptom of schizophrenia, stating that it is "normal" may invalidate the client's feelings and does not address the underlying distress. C. Correct. This response validates the client's feelings and demonstrates empathy by acknowledging the distress associated with the belief that government agents are after them.
D. Incorrect. While medication management is important in the treatment of schizophrenia, this response does not address the client's immediate concerns or validate their feelings of persecution.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Placing the crib in front of the window can pose a risk of injury if the infant gains access to the window blinds or falls out of the window.
B. Hanging toys across the crib rails can pose a risk of strangulation or choking if the infant becomes entangled in them.
C. Keeping the door to the bathroom closed prevents the infant from accessing potentially hazardous items such as medications, cleaning products, or small objects that may pose a choking hazard.
D. Setting the hot water heater at 140 degrees Fahrenheit increases the risk of scald burns for the infant. The water temperature should be set at or below 120 degrees Fahrenheit to prevent burns.
Correct Answer is A
Explanation
A. This is the correct answer. Flushing the tubing with water after medication administration ensures that the medication reaches the stomach and prevents any residue from remaining in the tubing.
B. Clamping the tubing is not typically necessary after medication administration and may impede the flow of subsequent medications or enteral feedings.
C. While checking the patency of the tubing is important before medication administration, it is not specifically performed after administering the medication.
D. Aspirating the tubing after medication administration is not necessary and may disrupt the delivery of the medication into the stomach.
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