The nurse is caring for a client in an acute mental health unit. The client states, “I believe my food is poisoned.” Which of the following should be an appropriate action by the nurse?
Taking steps to prevent the client from verbalizing the delusional thoughts.
Allowing the client to select food from vending machines.
Explaining that others eat the same food and feel safe.
Encouraging the client to discuss why someone would poison the food.
The Correct Answer is B
Choice A Reason:
Taking steps to prevent the client from verbalizing delusional thoughts is not therapeutic. It can lead to the client feeling misunderstood and unsupported. Nurses should provide a safe environment where clients feel comfortable expressing their thoughts and feelings.
Choice B Reason:
Allowing the client to select food from vending machines can be a temporary measure to address the immediate concern of the client’s fear of being poisoned. It provides a sense of control over their situation and may help to reduce anxiety related to eating.
Choice C Reason:
Simply explaining that others eat the same food and feel safe may not be effective for a client experiencing delusions. Delusions are fixed beliefs that are not easily changed by logical explanations or evidence to the contrary.
Choice D Reason:
Encouraging the client to discuss why someone would poison the food might validate the delusion and could reinforce the false belief. It’s important to acknowledge the client’s feelings without supporting the delusional content.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","E","F"]
Explanation
Choice A Reason:
Advocating for one's rights and the rights of others is not typically seen as a characteristic of aggressive communication. It can be a feature of assertive communication, where the individual stands up for their rights in a respectful and non-confrontational manner.
Choice B Reason:
Seeking to avoid expressing personal opinions is not characteristic of aggressive communicators. Aggressive communicators are more likely to forcefully express their opinions without regard for others' feelings or perspectives.
Choice C Reason:
Being controlling during conversations is a hallmark of aggressive communication. Aggressive communicators often dominate discussions, impose their views, and may disregard others' input.
Choice D Reason:
Feeling anxious about how messages will be received is not typically associated with aggressive communication. This trait is more aligned with passive communication, where individuals may be concerned about others' reactions and thus may hold back their true thoughts.
Choice E Reason:
Blaming others for misunderstandings is a common behavior in aggressive communication. Aggressive communicators may not take responsibility for their part in a conflict and instead put the blame on others.
Choice F Reason:
Frequently interrupting others during conversation is indicative of aggressive communication. This behavior demonstrates a lack of respect for others' contributions and a desire to control the conversation.
Correct Answer is ["A","D","E","F"]
Explanation
The correct answer is: A, D, E, and F.
Choice A reason:
Muscular tension, blood pressure, and triglycerides increase. Long-term stress can lead to chronic muscle tension, elevated blood pressure, and increased triglyceride levels. Chronic muscle tension is a common response to prolonged stress, often resulting in pain and discomfort. Elevated blood pressure is a well-documented effect of chronic stress, which can increase the risk of cardiovascular diseases. Increased triglycerides are also associated with prolonged stress, contributing to metabolic syndrome and cardiovascular risk.
Choice B reason:
Epinephrine is released, increasing heart and respiratory rates. This response is more characteristic of acute stress rather than long-term stress. Epinephrine (adrenaline) is released during the “fight-or-flight” response, causing immediate increases in heart rate and respiratory rate. However, this is a short-term physiological response and not typically sustained over long periods.
Choice C reason:
Corticosteroid release increases stamina and impedes digestion. While corticosteroids like cortisol are released during stress, their primary long-term effect is not to increase stamina but to manage energy by increasing blood glucose levels through gluconeogenesis. Chronic cortisol release can indeed impede digestion by diverting energy away from non-essential functions like the digestive system.
Choice D reason:
Cortisol is released, increasing gluconeogenesis and reducing fluid loss. Cortisol, a key stress hormone, is released during long-term stress and increases gluconeogenesis, which is the production of glucose from non-carbohydrate sources. This helps maintain energy levels during prolonged stress. Cortisol also helps in reducing fluid loss by promoting sodium retention in the kidneys.
Choice E reason:
Immune system functioning decreases, and risk of cancer increases. Chronic stress can suppress the immune system, making the body more susceptible to infections and diseases. Prolonged immune suppression can also increase the risk of cancer as the body’s ability to detect and destroy abnormal cells is compromised.
Choice F reason:
Risk of depression, autoimmune disorders, and heart disease increases. Long-term stress is linked to an increased risk of depression and other mental health disorders due to the continuous release of stress hormones affecting brain function. It can also trigger autoimmune disorders by causing chronic inflammation and dysregulation of the immune system. Additionally, the persistent high levels of stress hormonees can lead to heart disease by promoting hypertension and other cardiovascular issues.
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