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 D
Explanation
A. Normal pessimism of the elderly: This statement downplays the seriousness of the client’s feelings. Although some elderly individuals may experience sadness, these statements suggest a deeper issue that should not be considered normal.
B. A cry for sympathy: This response dismisses the client's feelings as attention-seeking, which could lead to missing a serious issue, such as depression or suicidal ideation.
C. Normal grieving: While grief can lead to feelings of sadness, the statements indicate a broader sense of hopelessness and worthlessness, which goes beyond normal grieving.
D. Evidence of high suicide potential: The client’s statements suggest feelings of hopelessness and despair, which are red flags for suicide risk, especially in elderly clients. This requires immediate assessment and intervention.
Correct Answer is A
Explanation
A. Tremors, headache, flushed face, and hallucinations: Acute alcohol withdrawal commonly presents with tremors, headache, flushed face, and hallucinations. These symptoms are characteristic of withdrawal syndrome and are important to monitor.
B. Psychomotor hypoactivity, hypotension, and increased appetite: Psychomotor hypoactivity and increased appetite are not typical symptoms of acute alcohol withdrawal. Hypotension may occur, but it is not the most prominent symptom.
C. Hypomania, bradycardia, and generalized seizures: Hypomania and bradycardia are not typical for alcohol withdrawal. Generalized seizures can occur in severe cases of withdrawal (delirium tremens), but hypomania is not a common symptom.
D. Anhidrosis, hypotonicity, and delusions: Anhidrosis (lack of sweating) and hypotonicity (decreased muscle tone) are not typical for alcohol withdrawal. Delusions may occur but are not the primary symptoms.
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