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. Auscultating below the umbilicus is not effective for assessing urinary retention.

B. Palpating the area above the pubic symphysis allows the nurse to assess for bladder distention, which is a direct indicator of urinary retention.

C. Measuring the girth of the lower abdomen can be useful but is less specific than palpation for assessing bladder fullness.

D. Observing the urine's appearance does not directly assess for urinary retention.

A. Guillain-Barre syndrome. B. Mycoplasma pneumonia. C. Cytomegalovirus. D. Epstein-Bar virus.

Correct Answer is A

Explanation

A. Guillain-Barre syndrome is a condition that can occur after an upper respiratory infection and is characterized by progressive weakness, numbness, and sometimes difficulty swallowing, which align with the client's symptoms.

B. Mycoplasma pneumonia primarily affects the respiratory system and does not typically cause lower extremity numbness and difficulty swallowing.

C. Cytomegalovirus can cause a range of symptoms but is not specifically associated with lower extremity numbness and difficulty swallowing.

D. Epstein-Barr virus is linked to infectious mononucleosis and does not typically cause lower extremity numbness and difficulty swallowing.

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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

Which assessment technique provides the most useful data when the nurse is concerned about possible urinary retention?

Correct Answer is B

Explanation

The nurse is assessing a client who recently had an upper respiratory infection and now presents to the emergency department with lower extremity numbness and difficulty swallowing. Based on these findings, this client is at greatest risk for which pathophysiological condition?

Correct Answer is A

Explanation

Two weeks after returning home from traveling, a client presents to the clinic with conjunctivitis and describes a recent loss in the ability to taste and smell. The nurse obtains a nasal swab to test for COVID 19. Which action is most important for the nurse to take?

While preparing a client's routine 0800 medications, the nurse opens the medication packaging and discards in the trash prior to scanning the barcode label. Which action should the nurse implement?

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