The nurse is caring for a client who has a history of experiencing delusions. The client describes singing in a concert in the afternoon for thousands of people. Which action should the nurse take?

Attempt to comfort the client by agreeing with the delusions and ask open ended questions.

Disagree with the statement and set clear limits on talking about it.

Immediately inform the provider that the client is experiencing a delusional episode.

Present a personal perception of reality in a non-confrontational manner.

Answer and Explanation

The Correct Answer is D

A. Agreeing with the delusions can reinforce the false beliefs and is not an effective therapeutic approach.

B. Disagreeing and setting limits may escalate the client's anxiety or agitation and does not address the delusion in a therapeutic manner.

C. While informing the provider is important, the immediate action should focus on therapeutic communication with the client.

D. Presenting a personal perception of reality in a non-confrontational manner helps the client to gently challenge their delusion and encourages a more grounded conversation.

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Correct Answer is D

Explanation

A. Morphine is used for pain management and is not contraindicated with sildenafil.

B. Aspirin is used for its antiplatelet effect and is not contraindicated with sildenafil.

C. Heparin is used as an anticoagulant and is not contraindicated with sildenafil.

D. Nitroglycerin is contraindicated with sildenafil because the combination can cause severe hypotension.

A. Focus on small achievable tasks, not taxing problems. B. Analyze past hurts and resentments to identify the source. C. Relax and reduce the amount of effort to solve the problem. D. Concentrate on and ventilate emotions when distressed.

Correct Answer is A

Explanation

A. Focusing on small achievable tasks helps to build a sense of accomplishment and reduce anxiety by breaking down overwhelming problems into manageable steps.

B. Analyzing past hurts may be useful in therapy, but for immediate coping, focusing on small tasks is more practical.

C. Relaxing and reducing effort might lead to avoidance rather than addressing anxiety.

D. Ventilating emotions is important but focusing on small tasks is more directly actionable for coping with anxiety and improving daily functioning.

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The nurse is caring for a client who has a history of experiencing delusions. The client describes singing in a concert in the afternoon for thousands of people. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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