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?"

Answer and Explanation

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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Correct Answer is D

Explanation

Choice A reason: Instructing the patient to wear constrictive clothing is incorrect, as it can worsen venous stasis ulcers by impeding blood flow.

Choice B reason: Encouraging the patient to keep legs in a dependent position is not recommended, as elevation helps in reducing venous pressure.

Choice C reason: Frequent ambulation is encouraged to promote blood circulation and prevent stasis.

Choice D reason: Applying compression stockings is a standard care practice to help reduce venous pressure and prevent fluid from pooling in the legs.

A. Surgical pause B. Time out C. Preoperative checklist D. Time in

Correct Answer is B

Explanation

Choice A reason: A surgical pause is not a commonly used term for this process.

Choice B reason: A time out is a standardized procedure used to verify the correct patient, procedure, and site before surgery begins.

Choice C reason: The preoperative checklist is a broader list of tasks completed before surgery, not the specific pause for verification.

Choice D reason: Time in is not a recognized term for this verification process in the surgical setting.

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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?

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The nurse is caring for a patient with venous stasis ulcers. What actions should the nurse take?

Correct Answer is D

Explanation

After positioning the patient on the surgical table and applying the safety strap, the surgical team pauses and verifies the patient and surgical information. What is this called?

Correct Answer is B

Explanation

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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?