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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Acute pain deep within the eye following laser trabeculoplasty surgery may indicate a serious complication such as increased intraocular pressure or infection. It is crucial to report this symptom to the surgeon immediately for further evaluation and management.
B. Administering an antiemetic is not directly related to addressing the acute eye pain.
C. Applying bilateral eye shields can help with photosensitivity but does not address the underlying cause of the acute pain.
D. Beginning postoperative prophylactic antibiotics may be necessary but does not address the immediate concern of the acute pain reported by the client.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A","dropdown-group-3":"C"}
Explanation
Pressure injuries: These can indicate neglect or inadequate care, as they often develop from prolonged periods of immobility or poor hygiene.
Poor hygiene: A foul odor and unclean environment, along with a lack of clothing, can be signs of neglect or mistreatment.
Malnutrition: The client's low weight (98 lb or 44.5 kg) and a lack of appropriate nutrition could indicate inadequate care and potential mistreatment, contributing to overall poor health and well-being.
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