As a nurse approaches the nurses' station, a client diagnosed with a delusional disorder raises his voice and says, "You're following me. What do you want?" To prevent escalating fear and anger, the nurse takes a nonthreatening posture and makes which response in a calm voice?
"Are you frightened?"
"You know I'm not following you."
"You'll have to go into seclusion if you continue to threaten me."
"I'm sorry if I frightened you. I was returning to the nurses' station after going out for lunch."
The Correct Answer is D
A. "Are you frightened?" This response is empathetic but may inadvertently reinforce the client's delusional thinking by focusing on the fear rather than addressing the delusion.
B. "You know I'm not following you." This response directly challenges the client's delusion, which could provoke defensiveness and escalate the situation.
C. "You'll have to go into seclusion if you continue to threaten me." This response is confrontational and may escalate the situation further by implying a threat, which could increase the client's fear and anger.
D. "I'm sorry if I frightened you. I was returning to the nurses' station after going out for lunch." This response acknowledges the client's feelings without reinforcing the delusion and provides a simple, non-threatening explanation for the nurse's actions. It helps de-escalate the situation by maintaining a calm, non-confrontational tone.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
A. Monitoring the client for neuroleptic malignant syndrome for up to 2 months after initiating the drug. Neuroleptic malignant syndrome (NMS) is a rare but serious adverse effect of antipsychotic medications. Monitoring for NMS, especially during the first few months of treatment, is crucial.
B. Encouraging the client to report signs of diabetes, such as increased thirst, hunger, and urination. Some antipsychotics, particularly second-generation antipsychotics, are associated with an increased risk of metabolic syndrome, including diabetes. Clients should be educated to report symptoms suggestive of hyperglycemia.
C. Advising the client to report weight gain and skin rashes to the health care provider immediately. Weight gain is a common side effect, particularly with second-generation antipsychotics. Skin rashes could indicate an allergic reaction, including serious conditions like Stevens-Johnson syndrome, requiring immediate medical attention.
D. Using the Abnormal Involuntary Movement Scale (AIMS) to assess for neurologic adverse effects. The AIMS scale is used to assess for tardive dyskinesia and other extrapyramidal symptoms, which are potential adverse effects of antipsychotic medications.
E. Administering the medication subcutaneously when the client is unable to swallow effectively. Antipsychotic medications are generally not administered subcutaneously. If a client cannot swallow, an alternative route such as intramuscular injection or an orally disintegrating tablet might be used.
Correct Answer is B
Explanation
A. Increasing forgetfulness and confusion: These symptoms are more characteristic of Alzheimer's disease or other types of dementia, not Parkinson's disease. While cognitive decline can occur in later stages of PD, it is not typically an initial symptom.
B. Tremors and muscle rigidity: Tremors (often starting in one hand) and muscle rigidity are hallmark initial symptoms of Parkinson's disease. These motor symptoms are among the most common early manifestations.
C. Visual disturbances and muscle weakness: Visual disturbances are not typically associated with early Parkinson's disease, and muscle weakness is not an initial symptom but could occur later due to rigidity and bradykinesia.
D. Fatigue and respiratory difficulties: While fatigue can occur, respiratory difficulties are not typically initial symptoms of Parkinson's disease and are more associated with later stages or other conditions.
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