A client, who is wearing dirty clothes and has a foul body odor, comes to the clinic reporting feeling scared because of a stalker. Which action is most important for the nurse to take?
Recommend that the client talk with a social worker today.
Offer the client a safe place to relax before the Interview.
Assure client of an interview with the healthcare provider today.
Ask the client to describe the stalker and If It is frequent.
The Correct Answer is B
A. Referral to a social worker may be beneficial for long-term support and resources. However, it does not address the client’s immediate sense of fear and need for safety.
B. Offering a safe place to relax is the priority because the client is expressing fear and possible threat from a stalker. Ensuring immediate safety and reducing anxiety aligns with the priority principle of protecting the client from harm.
C. Arranging an interview with the healthcare provider is important for further evaluation and planning. However, it does not address the client’s immediate emotional distress and perceived danger.
D. Asking for details about the stalker may be part of assessment, but it should occur after the client feels safe. Gathering information is secondary to ensuring the client’s immediate safety and emotional stabilization.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale: The nurse's response regarding watery eyes and diarrhea is not directly related to the client's concern about the medication's effect on blood glucose levels.
Choice B rationale: This response minimizes the potential side effects, which is not accurate. Second-generation antipsychotics are associated with metabolic side effects, including changes in blood glucose levels.
Choice C rationale: Offering an education sheet is helpful but does not directly address the client's specific concerns about the medication's impact on blood glucose levels.
Choice D rationale: This response acknowledges the client's concern, provides information about the general tolerability of the medication, and invites the client to share more about their specific worries. It encourages open communication and allows the nurse to address the client's concerns more effectively.
Correct Answer is C
Explanation
Choice A rationale: Telling the client that irrational thinking is a symptom of schizophrenia may not be well-received and could lead to increased resistance. It is essential to address the immediate concern of food refusal.
Choice B rationale: Assuring the client that all food served in the hospital is safe to eat may not be sufficient, especially if the client has strong delusional beliefs about poisoning. Offering food in unopened containers is a more practical approach. Choice C rationale: Providing the client with food in unopened containers is a reasonable intervention. It addresses the client's concerns about poisoning and ensures that the food is perceived as safe.
Choice D rationale: Obtaining an order for a tube feeding for the client may be considered if the client continues to refuse solid food. However, providing food in unopened containers is an initial step to encourage the client to eat.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
