A nurse is caring for a client in an inpatient mental health facility. The client tells the nurse that the government is reading her mail. Which of the following responses should the nurse make?

"It must be frightening to think that someone is reading your mail."

"You know that's not true, because it is against the law for others to read your mail."

"All of your letters come sealed, so that seems unlikely."

"Why do you think the government wants to read your mail?"

Answer and Explanation

The Correct Answer is A

A. This response acknowledges the client's feelings and validates their experience without confirming or denying the delusion.
B. This response challenges the client's belief and may cause distress or exacerbate paranoia.

C. While factually correct, this response may not address the client's underlying concerns or feelings.
D. This response may invalidate the client's experience and may not effectively address the delusional belief.

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Correct Answer is A

Explanation

A. This response directly addresses the potential for self-harm, which is a critical concern when a client expresses hopelessness. It is an open-ended question that invites the client to discuss their feelings and provides the nurse with information to assess the client's safety.
B. Asking the client a why question may not be alright and this may make them to be guarded.
C. This response may come off as dismissive and lacks empathy towards the client's feelings.
D. Suggesting medication without further assessment is premature and may not address the root cause of the client's statement.

A. "Ask a family member to check the locks for you at night." B. "Keep a journal of how often you check the locks each night." C. "Focus on abdominal breathing whenever you go to check the locks." D. "Snap a rubber band on your wrist when you think about checking the locks."

Correct Answer is D

Explanation

A. Asking a family member to check the locks for the client may alleviate immediate anxiety but does not address the underlying obsessive-compulsive behavior or provide coping mechanisms for the client to manage their symptoms independently.
B. Keeping a journal of checking behaviors may be part of exposure and response prevention therapy but does not directly address the intrusive thoughts associated with obsessive- compulsive disorder in the moment.
C. Focusing on abdominal breathing is a relaxation technique that may help reduce overall anxiety but does not specifically target the intrusive thoughts associated with obsessive- compulsive disorder.
D. Using a rubber band to snap on the wrist when the client thinks about checking the locks is a form of aversion therapy, which is a component of thought stopping technique. This technique helps interrupt and redirect the obsessive thoughts, promoting awareness and control over compulsive behaviors.

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A nurse is caring for a client in an inpatient mental health facility. The client tells the nurse that the government is reading her mail. Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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