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 B

Explanation

A. Identifying information as a late entry is not appropriate until the system issue is resolved.

B. Notifying the information services department is essential to address the system failure and seek assistance in resolving the issue.

C. Waiting for notification may delay addressing the problem and does not help in the immediate resolution.

D. Printing the EMR from the backup server might be necessary later but does not address the immediate need to fix the system issue.

A. Ensure that prescribed medications are kept in a safe place in the room. B. Replace paper trash bags with plastic biohazard bags. C. Remove soft drink cans from the nurse's desk and patient lounge. D. Take the client's cellular telephone and provide a telephone in the room.

Correct Answer is C

Explanation

A. Ensuring medications are kept in a safe place is important but may not directly impact safety in the milieu.

B. Replacing paper trash bags with biohazard bags is unnecessary unless there is a specific reason related to infection control.

C. Removing soft drink cans can prevent them from being used inappropriately (e.g., for self-harm or as weapons), contributing to a safer environment.

D. Taking the client's cellular telephone and providing a room telephone may be necessary for some clients but is not a universal safety measure.

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Body System	Assessment Finding
Neurological	Restless Awake and alert Anxious
Respiratory	Respiratory rate 28 breaths/minute Oxygen Saturation 90% on room air Productive cough
Cardiovascular	Heart rate 101 beats/minute Capillary refill 4 seconds Blood pressure 145/89 mm Hg

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 B

Explanation

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Correct Answer is C

Explanation

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