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 C

Explanation

Choice A reason: Conversion typically refers to the expression of psychological distress through physical symptoms, which is not the case here.

Choice B reason: Undoing is a defense mechanism where a person tries to 'undo' an unhealthy thought or behavior with a healthier one, which does not apply to Michael's situation.

Choice C reason: Compensation is a defense mechanism where a person overachieves in one area to make up for deficiencies in another, which describes Michael's actions.

Choice D reason: Sublimation involves channeling unacceptable impulses into socially acceptable activities, which is not explicitly indicated in this scenario.

A. Adjust the thermostat so that the environment is warm. B. Rest with the legs above heart level. C. Apply a heating pad on a low setting to help relieve leg pain. D. Wear antiembolic stockings during the day.

Correct Answer is A

Explanation

Choice A reason: Keeping the environment warm can help prevent the vasoconstriction that can exacerbate PAD symptoms.

Choice B reason: Resting with the legs above heart level is not typically recommended for PAD as it can reduce arterial blood flow to the legs.

Choice C reason: Applying a heating pad is not recommended for clients with PAD because they may have decreased sensation and could suffer burns.

Choice D reason: Wearing antiembolic stockings during the day can help improve circulation, which is beneficial for clients with PAD.

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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?

Nursing Test Bank

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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