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?
"There is no one who will hurt you.".
"You seem quite frightened right now.".
"You are in a safe place.
"What would you like to see me do to protect you?".
The Correct Answer is B
The correct answer is B. "You seem quite frightened right now."
Choice A rationale:
This statement dismisses the client's feelings and may not provide the reassurance they need. It could also escalate the situation if the client feels misunderstood or ignored.
Choice B rationale:
This response acknowledges the client's emotions and validates their experience, which can help build trust and de-escalate the situation. It shows empathy and understanding, which are crucial in managing delusions.
Choice C rationale:
While this statement aims to reassure the client, it may not address their immediate emotional state. The client might not feel safe despite being told they are, so it might not be as effective in calming them down.
Choice D rationale:
This response could inadvertently reinforce the client's delusions by implying that their fears are valid and that the nurse should take action based on those delusions. It might also confuse the client further.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Choice B rationale:
Choice C rationale:
Severe motor dysfunction determines the extent of successful habilitation is not entirely accurate. While the severity of motor dysfunction does play a role in the challenges a child with CP may face, it does not solely determine the extent of successful habilitation. Many factors, including early intervention, therapy, and individualized care, can influence a child's progress and potential for improvement.
Choice D rationale:
Continued development of the brain lesion determines the child's outcome is not an accurate statement. CP is primarily caused by non-pro
Correct Answer is D
Explanation
Choice A rationale:
Washing the patient's left side first and then moving to the right side does not demonstrate an individualized approach or consideration for the patient's preferences and abilities. It is important to involve the patient in the decision-making process, especially when they have hemiparesis, to promote their autonomy and comfort.
Choice B rationale:
Washing the patient's right side first and then moving to the left side does not consider the patient's preference and may not align with their abilities or comfort. It is essential to prioritize the patient's preferences and needs.
Choice C rationale:
Washing both sides of the patient at the same time, starting from the head and moving down, may not be feasible or comfortable for the patient, especially if they have hemiparesis. This approach does not demonstrate an individualized care plan based on the patient's specific condition.
Choice D rationale:
Asking the patient which side they prefer to wash first and then following their preference is the most patient-centered and appropriate approach. This approach respects the patient's autonomy and ensures that their needs and comfort are prioritized during the bathing process. It allows for individualized care based on the patient's abilities and preferences.
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