A nurse is sitting with a client in the dayroom. The client jumps up and states, "There are snakes coming toward me!" Which of the following responses should the nurse make?

"What do you usually do when this happens?"

"Let's move to a different room to avoid the snakes."

"I understand that you're seeing snakes, but I don't see any."

"Would you like to play cards?"

Answer and Explanation

The Correct Answer is C

A. "What do you usually do when this happens?": While exploring coping strategies can be helpful, this response does not immediately address the client’s distress or provide reassurance. The client may remain frightened without acknowledgment of their current experience.

B. "Let's move to a different room to avoid the snakes.": Suggesting action to avoid a hallucination reinforces the false perception and can increase confusion or anxiety. It does not help the client differentiate between reality and hallucination.

C. "I understand that you're seeing snakes, but I don't see any.": This response acknowledges the client’s experience without validating the hallucination as reality. It provides support and reality orientation, helping reduce anxiety and maintain a therapeutic presence.

D. "Would you like to play cards?": Offering a distraction can be useful after addressing the hallucination, but initially ignoring the client’s immediate distress may make them feel unheard and unsafe. Immediate acknowledgment is a higher priority.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is D

Explanation

A. "I still believe my cancer will go into remission.": Denial of the terminal prognosis may indicate ineffective coping, as the client is not fully accepting the reality of their condition and may delay necessary end-of-life planning.

B. "I hope to have surgery to cure my cancer.": Hoping for a curative treatment when the disease is terminal reflects unrealistic expectations and may suggest difficulty accepting the prognosis. This statement does not demonstrate effective coping.

C. "I need to return to work as soon as my treatment is complete.": Focusing on returning to work implies denial of disease progression and potential limitations, which can interfere with emotional preparation and adaptation to terminal illness.

D. "I should start making my funeral arrangements.": Planning for end-of-life events reflects acceptance of the terminal diagnosis and proactive engagement in advance care planning. This demonstrates realistic coping and psychological preparation for death.

A. "We have to notify your insurance company that you are here." B. "We have to inform your immediate family members that you are here." C. "We have to report your admission to the National Alliance on Mental Illness." D. "We have to obtain your permission to discuss your care with others."

Correct Answer is D

Explanation

A. "We have to notify your insurance company that you are here.": While insurance may require documentation for billing purposes, this statement does not address the client’s concern about confidentiality or privacy. It could increase anxiety and reduce trust in the nurse-client relationship.

B. "We have to inform your immediate family members that you are here.": Family notification typically requires the client’s consent unless there is a safety concern or legal mandate. Automatically informing family without permission violates confidentiality and the client’s rights under HIPAA or similar privacy laws.

C. "We have to report your admission to the National Alliance on Mental Illness.": Mental health admissions are not reported to advocacy organizations like NAMI. This statement is inaccurate and could cause unnecessary fear or confusion for the client.

D. "We have to obtain your permission to discuss your care with others.": Respecting confidentiality is a core ethical and legal responsibility. The nurse should clarify that the client’s consent is required before sharing any information with others, which addresses the client’s concerns and supports trust in the therapeutic relationship.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is sitting with a client in the dayroom. The client jumps up and states, "There are snakes coming toward me!" Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has terminal cancer and is receiving palliative care. Which of the following statements indicates that the client is demonstrating effective coping?

Correct Answer is D

Explanation

A nurse in an inpatient mental health facility is caring for a client who states, "I do not want anyone to know I am in a mental hospital." Which of the following responses should the nurse make?

Correct Answer is D

Explanation

A nurse at an inpatient mental health facility is receiving report on four clients. Which of the following clients should the nurse see first?

A nurse is assisting with reminiscence therapy for a group of older adult clients. Which of the following strategies should the nurse implement?

A nurse at a community mental health center is caring for a client who has bipolar disorder. The nurse should recognize that which of the following statements is an indication that the client is in the manic phase?

A nurse is collecting data from a client who reports cessation of nicotine use. Which of the following manifestations should the nurse expect? (Select all the apply.)

A nurse is caring for a young adult client who has major depressive disorder and has been found legally incompetent. The client requires informed consent for abdominal surgery. The nurse should recognize that which of the following people can consent to the surgery?

A nurse is reinforcing teaching with a client about haloperidol. Which of the following instructions should the nurse include in the teaching?

A nurse is assisting in the care of a client on an acute care mental health unit. Select words from the choices to fill in each blank in the following sentence. The nurse should immediately follow up on the client's _____ and _____

A nurse is caring for a client who has a depressive disorder. Which of the following factors should the nurse identify as a risk factor for developing this condition?