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A client with delusions tells the nurse, "You aren't doing your job.
Go get those people over there and shoot them before they get me." Which statement is the nurse's best response?

A.

"There is no one who will hurt you.".

B.

"You seem quite frightened right now.".

C.

"You are in a safe place.No one can get to you here.".

D.

"What would you like to see me do to protect you?".

Answer and Explanation

The Correct Answer is B

 

The correct answer is choice B. “You seem quite frightened right now.”.

 

Choice A rationale:

 While reassuring the client that no one will hurt them is well-intentioned, it may not effectively address the client’s immediate emotional state or validate their feelings.

 

Choice B rationale:

 Acknowledging the client’s fear helps validate their emotions and opens a pathway for further therapeutic communication. It shows empathy and understanding, which can help build trust and provide comfort.

 

Choice C rationale:

 Telling the client they are in a safe place is reassuring, but it may not fully address the client’s immediate emotional distress or validate their feelings.

 

Choice D rationale:

 Asking the client what they would like the nurse to do to protect them might reinforce the delusion and could potentially escalate the situation. It is more effective to acknowledge the client’s feelings and provide reassurance.


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Related Questions

Correct Answer is ["21"]

Explanation

Let’s calculate the infusion rate step by step:

  1. Convert 1 liter to mL: 1 liter = 1000 mL.
  2. Calculate total infusion time in minutes: 12 hours = 12 × 60 = 720 minutes.
  3. Calculate the rate in mL/min: Rate = Total Volume ÷ Total Time = 1000 mL ÷ 720 min = 1.39 mL/min.
  4. Calculate the drip rate in gtt/min: Drip Rate = Rate (mL/min) × Drip Factor (gtt/mL) = 1.39 mL/min × 15 gtt/mL = 20.85 gtt/min.

If rounding is required, we round to the nearest whole number. So, the nurse should regulate the infusion to 21 gtt/min.

Correct Answer is B

Explanation

Choice A rationale:

Objective data. Rationale: Objective data are observable and measurable facts obtained through physical examination or diagnostic tests. The statement incorrectly labels the data as objective when it is, in fact, based on the client's feelings and perceptions, making it subjective.

Choice B rationale:

Subjective data. Rationale: Subjective data are information provided by the client, including their feelings, perceptions, and experiences. The statement correctly labels the data as subjective, as it reflects the client's report of thirst and hunger.

Choice C rationale:

Primary data. Rationale: Primary data are original data collected directly from the source, such as a client's medical history or interview. However, this classification does not address the nature of the data as being subjective or objective, so the statement does not provide a complete answer.

Choice D rationale:

Secondary data. Rationale: Secondary data are data obtained from sources other than the client, such as medical records or research studies. Similar to choice C, this classification does not address the nature of the data as being subjective or objective.

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