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 A
Explanation
- Rationale for A: The name and medical record number are unique identifiers that are used to accurately match a newborn with their medical records and ensure that the correct medication is administered. This method of identification minimizes the risk of medical errors, which is crucial in a hospital setting where multiple newborns may be present.
- Rationale for B: While the birth date and mother's name are important, they may not be as effective for identification because multiple newborns could share a birth date, and there could be more than one mother with the same name in the maternity ward.
- Rationale for C: Age and diagnosis are not specific enough for the identification of a newborn when administering medication. Age is not a distinguishing factor in a neonatal unit, and the diagnosis could apply to multiple infants.
- Rationale for D: Footprints and identification number can be used as secondary identifiers. However, footprints may change rapidly as the newborn grows, and the identification number should be cross-referenced with the name and medical record number for accurate identification.
Correct Answer is D
Explanation
A. Anger is characterized by feelings of hostility and frustration, which may arise as the client acknowledges the reality of their situation.
B. Depression involves feelings of sadness, hopelessness, and despair, often occurring as the client comes to terms with the impending loss or changes associated with their condition.
C. Acceptance involves acknowledging and coming to terms with the reality of the situation without resistance or denial.
D. Denial is a defense mechanism where the client refuses to acknowledge the reality of their situation, such as the need for a lengthy recovery period after open heart surgery. The client's statement reflects denial, as they are minimizing the seriousness of the surgery and its impact on their recovery.
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