A nurse in an acute care mental health facility is sitting with a client who has schizophrenia. The client whispers to the nurse, "I'm being kept in this prison against my will. Please try to get me out." Which of the following responses should the nurse make?
"We are here to help you and give you the care that you need right now."
"Do you feel that you don't belong here?"
"Try to take some deep breaths, and I'm sure you'll feel better."
"Why do you feel that you need to leave?"
The Correct Answer is A
Choice A reason: This response is empathetic and reassuring, affirming the nurse's role in providing care and support, which is essential in managing patients with schizophrenia who may experience feelings of paranoia or imprisonment.
Choice B reason: Asking if the patient feels they don't belong could reinforce feelings of alienation or paranoia. It's important to provide reassurance rather than question their sense of belonging.
Choice C reason: While deep breathing can be a calming technique, assuring the patient they will feel better may not address their immediate concerns or the reality of their feelings.
Choice D reason: Asking why they feel the need to leave could challenge the patient's experience and potentially escalate their distress. It's important to validate their feelings and provide reassurance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: An appendectomy is a surgical procedure to remove the appendix, typically due to appendicitis.
Choice B reason: Removal of the colon is known as a colectomy, not an appendectomy.
Choice C reason: Cutting into the appendix may be part of the procedure, but appendectomy specifically refers to the removal of the appendix.
Choice D reason: Repair of the appendix is not a common procedure; appendectomies are performed to remove the appendix, not repair it.
Correct Answer is C
Explanation
Choice A reason: Lying prone may be part of the care plan but is not specifically aimed at promoting ambulation.
Choice B reason: Coordination exercises are important but secondary to building the strength necessary for using mobility aids.
Choice C reason: Building upper body strength is essential for a patient who has had an above-the-knee amputation to be able to use assistive devices for ambulation effectively.
Choice D reason: Maintaining residual limb elevation is important for reducing swelling but does not directly promote ambulation.
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