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.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is D
Explanation
Choice A reason: While nutrition is important, it is not the immediate priority in the management of septic shock.
Choice B reason: Monitoring IV fluids is important, but the initial priority is to treat the infection causing the septic shock.
Choice C reason: Obtaining blood cultures is important, but it should not delay the administration of antibiotics.
Choice D reason: The administration of broad-spectrum antibiotics within one hour of diagnosing septic shock is critical to improve outcomes and is considered a priority action.
Correct Answer is C
Explanation
Choice A reason: The use of a heating pad on the operative site is not typically recommended immediately post-surgery due to the risk of bleeding and swelling.
Choice B reason: Patients are encouraged to mobilize as soon as possible after surgery to prevent complications such as deep vein thrombosis and pulmonary embolism.
Choice C reason: The use of a CPM machine is common after total hip replacement surgery to help restore joint function and prevent stiffness.
Choice D reason: Using a special soap the evening before surgery is part of the preoperative preparation to reduce the risk of infection.
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