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. While reassurance is important, simply telling the client that she will adjust to changes to her body may minimize her concerns and not adequately address her emotional needs. It's important to offer support and provide resources to help the client cope with potential changes.
B. While an occupational therapist may be able to provide valuable support, their role may not specifically address the client's concerns about body image changes related to breast cancer treatment.
C. Reach to Recovery is a program offered by the American Cancer Society that connects newly diagnosed breast cancer patients with trained volunteers who have experienced breast cancer themselves. These volunteers can offer support, guidance, and practical tips for coping with the physical and emotional challenges of breast cancer diagnosis and treatment. Initiating a referral to this program can provide the client with valuable support from someone who has been through a similar experience.
D. While surgery may be an option for restoring the appearance of the breast, it may not fully address the client's concerns about potential changes to her body image. Additionally, not all breast cancer patients undergo surgery or choose reconstructive procedures, so it's important to provide support and resources regardless of the treatment chosen.
Correct Answer is D
Explanation
A. Massaging areas around the edge of the cast with lotion can introduce moisture and compromise the integrity of the cast, increasing the risk of skin breakdown and infection.
B. Elevating the extremity when the client is resting in bed helps reduce swelling and improve circulation, promoting healing. It is an appropriate action for a client with a cast.
C. Inserting objects under the cast can damage the skin, increase the risk of infection, or disrupt the integrity of the cast.
D. Numbness can indicate impaired circulation or nerve compression and warrants immediate assessment, making this the correct action.
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