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 B
Explanation
A. Diarrhea: Opiates typically cause constipation, not diarrhea. Diarrhea is not a common finding with opiate use.
B. Pinpoint-sized pupils: Opiates commonly cause miosis, or pinpoint pupils. This is a classic sign of opiate use and is important for assessment.
C. Weight gain: Opiate use is not typically associated with weight gain; in fact, it can sometimes lead to decreased appetite and weight loss.
D. Bulimia: Bulimia is an eating disorder characterized by binge eating and purging. It is not a typical effect of opiate use.
Correct Answer is A
Explanation
A. Drink adequate noncaffeinated and non-alcoholic beverages: Xerostomia (dry mouth) can be alleviated by staying hydrated with noncaffeinated and non-alcoholic beverages, which help to moisten the mouth and improve comfort.
B. Take nutrient-dense foods or to combine plant-based proteins: While nutrient-dense foods are important for overall health, they do not specifically address the issue of xerostomia. Plant-based proteins do not directly impact the symptoms of dry mouth.
C. Take protein-based liquid supplements: Protein-based liquid supplements are not specifically designed to address dry mouth and may not help in alleviating xerostomia.
D. Get dental care and practice dental hygiene daily: While dental care and hygiene are important for overall oral health, they do not specifically address xerostomia. Drinking fluids is more directly helpful for managing dry mouth.
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