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 C
Explanation
Choice A reason: Hypertension is not typically a direct complication of inhaled anesthetics.
Choice B reason: Urinary retention can occur postoperatively but is not specifically associated with inhaled anesthetics.
Choice C reason: Laryngospasm is a potential complication of inhaled anesthetics, which can occur due to irritation of the airway during anesthesia.
Choice D reason: Anxiety is not a complication of inhaled anesthetics; it is more likely to be associated with preoperative stress.
Correct Answer is ["B","C","D"]
Explanation
Choice A reason: Observing nonverbal communication is a valid nursing intervention for assessing a patient's anxiety level.
Choice B reason: Maximizing stimuli can overwhelm a patient with anxiety and is not a recommended intervention.
Choice C reason: Discouraging activities is not recommended as activities can be a form of therapy for anxiety disorders.
Choice D reason: Documenting only positive changes is not appropriate as all changes, positive or negative, should be documented for a comprehensive understanding of the patient's condition.
Choice E reason: Encouraging patients to verbalize thoughts and feelings is a therapeutic intervention that can help manage anxiety.
Choice F reason: Observing for signs of suicidal thoughts is crucial as anxiety disorders can increase the risk of suicide.
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