A nurse is caring for a client who has a history of alcohol use disorder and has been hospitalized for alcohol intoxication. The nurse enters the room and finds the client shouting "Get those bugs off of me." Which of the following responses should the nurse make?
"I'm sure that the bugs you see will not harm you."
"I don't see any bugs, but you seem very frightened."
"Let's get out of your room so that the bugs will not bother you
“There are no bugs in here. This is part of your illness."
The Correct Answer is B
A. "I'm sure that the bugs you see will not harm you.": This response validates the hallucination and may increase the client's anxiety.
B. "I don't see any bugs, but you seem very frightened.": This response maintains reality orientation while acknowledging the client’s emotional state, a therapeutic and non-confrontational approach.
C. "Let's get out of your room so that the bugs will not bother you": This reinforces the hallucination and may worsen disorientation.
D. “There are no bugs in here. This is part of your illness.": This is too blunt and dismissive, potentially increasing defensiveness or agitation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. overdose: Refers to consuming a toxic amount that may be life-threatening, often requiring emergency intervention.
B. intoxication: Intoxication is the physiological and psychological disruption caused by a substance, impairing functioning.
C. tolerance: Tolerance refers to needing more of a substance to achieve the same effect, not acute interference with function.
D. dependency: Dependency is a chronic condition characterized by compulsion and inability to stop use, not a single event of impairment.
Correct Answer is C
Explanation
A. duty to report
This refers to reporting suspected abuse or neglect (e.g., child or elder abuse), not specifically about preventing self-harm.
B. duty to pr
Incomplete option-likely a typographical error. Not a valid or recognized legal/ethical term.
C. protect
Healthcare professionals have a legal and ethical duty to protect patients from harming themselves, including through supervision, intervention, and safety precautions.
D. duty to warn
This applies when a client threatens to harm others, and the provider must warn the intended victim or authorities-not self-harm situations.
E. duty to medicate
This is not a recognized legal or ethical duty. Medication may be part of care, but not a professional “duty” to medicate.
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