A nurse in a mental health facility is collecting a blood specimen from a client.
The client is hallucinating and states, "That looks like a snake, and I won't let it take all of my blood.”. Which of the following responses should the nurse make?.
"I'm using a syringe to obtain your blood, not a snake.”.
"Your provider requires this blood specimen.”.
"You must be mistaken.
Snakes cannot be in the clinic.”.
The Correct Answer is D
(Null)
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Discouraging visitation from the client’s family could increase feelings of isolation and confusion, which could exacerbate delirium.
Choice B rationale:
A high-stimulation environment could overstimulate the client and worsen delirium.
Choice C rationale:
Limiting the client’s need to make decisions can reduce stress and confusion, which can help manage delirium.
Choice D rationale:
Keeping the client’s room dark at night could disrupt the client’s sleep-wake cycle and potentially worsen delirium.
Correct Answer is D
Explanation
Choice A rationale:
This statement is generalizing the client’s feelings, which can lead to a lack of individualized care.
Choice B rationale:
This statement is not acknowledging the client’s feelings of grief, which can lead to a lack of trust in the nurse-client relationship.
Choice C rationale:
This statement is self-disclosing personal information, which can lead to boundary violations in the nurse-client relationship.
Choice D rationale:
This statement is encouraging the client to express their feelings, which can help in the grieving process.
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