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
Related Questions
Correct Answer is A
Explanation
Choice A reason: The first step should always be to assess the patient's physical state to rule out any immediate life-threatening conditions before proceeding with psychiatric interventions.
Choice B reason: Administering medication may be necessary, but it should not precede an assessment of the patient's vital signs.
Choice C reason: While instructing the patient to sit and breathe deeply can help alleviate symptoms of anxiety, it is not the first action to take before assessing the patient's vital signs.
Choice D reason: Imagery exercises can be helpful for managing anxiety, but they are not the priority before ensuring the patient's physiological stability.
Correct Answer is B
Explanation
Choice A reason: Permanent mobility impairment is a possible complication, but it is not the most common concern immediately following a closed reduction and cast placement.
Choice B reason:Older adults are at a higher risk for delayed healing of fractures due to factors such as reduced bone density, slower cellular repair mechanisms, and potential comorbidities like diabetes or osteoporosis. While permanent mobility impairment, malalignment, and bone infections are possible complications of fractures, they are less common in routine cases of closed reduction and casting, especially if proper care and follow-up are provided. Delayed healing is a more likely complication due to age-related changes in bone health.
Choice C reason: Malalignment of healed bones is a potential long-term complication, but it is not the immediate concern post-cast placement.
Choice D reason: Bone infections (osteomyelitis) are rare following closed fractures treated with casting, especially when there is no open wound. Infections are more likely with open fractures or surgical interventions.
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