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?"
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Methadone hydrochloride is not indicated for the management of alcohol intoxication or withdrawal. It is primarily used for opioid addiction treatment.
B. While monitoring for orthostatic hypotension is important in clients with alcohol use disorder, implementing seizure precautions is a higher priority because alcohol withdrawal can lead to
seizures.
C. Acidifying the client's urine is not indicated in the care of an intoxicated client with alcohol use disorder.
D. Implementing seizure precautions is essential in clients with alcohol use disorder who are at risk for alcohol withdrawal syndrome, which can include seizures as a potential complication.
Correct Answer is D
Explanation
A. Explaining implied consent to the client's family does not address the need for obtaining informed consent for a legally incompetent client.
B. Asking the charge nurse to obtain informed consent may not be appropriate, as the responsibility for obtaining consent typically falls on the healthcare provider or a designated individual.
C. While the social worker may be involved in the process of obtaining consent for a legally incompetent client, it is not their sole responsibility, and the nurse should be actively involved in the process.
D. When a client has been declared legally incompetent, consent must be obtained from the client's legally appointed guardian or surrogate decision-maker.
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