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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Free Nursing Study Resources

Correct Answer is ["A","B","C","D","E","F","G","H","I","J"]

Explanation

Impaired cognition, insomnia, seizures

Increased blood pressure, increased heart rate, diaphoresis

Lack of appetite, vomiting

Malaise, tremulousness

A. Report the information to local authorities. B. Avoid reporting the information provided by the client because it is confidential. C. Tell risk management about the client's plan to hurt their partner. D. Notify the provider that the client should stay longer at the facility to work on anger management.

Correct Answer is A

Explanation

A. Safety is paramount, and if a client expresses intent to harm someone, it must be taken seriously and reported to local authorities to prevent harm and ensure the safety of the potential victim.
B. Confidentiality is important, but when there is a threat to harm others, the duty to warn and protect overrides confidentiality.
C. While informing risk management may be appropriate in some situations, when there is an imminent threat of harm, immediate action is necessary, which includes reporting to local authorities.
D. Delaying discharge to work on anger management may not be sufficient to ensure the safety of the potential victim. Reporting the threat to local authorities is necessary to prevent harm.

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Body system	Findings
Neurological	Impaired cognition

	Insomnia Seizures
Cardiovascular	Increased blood pressure Increased heart rate Diaphoresis
Gastrointestinal	Lack of appetite Vomiting
Musculoskeletal	Malaise Tremulousness

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

Correct Answer is ["A","B","C","D","E","F","G","H","I","J"]

Explanation

A nurse is caring for a client who has antisocial personality disorder and reports planning to hurt their partner upon discharge. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is caring for a client who is taking citalopram. For which of the following adverse effects should the nurse monitor the client?

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A nurse is assisting with obtaining informed consent for a client who has been declared legally incompetent. Which of the following actions should the nurse take?

An older adult client is brought to the mental health clinic by her daughter. The daughter reports that her mother is not eating and seems uninterested in routine activities. The daughter states, "I'm so worried that my mother is depressed." Which of the following responses should the nurse make?