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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. a patient admits himself to a mental health care facility and can leave when they desire:
This describes voluntary admission, not involuntary. Voluntary patients can request discharge unless a danger is assessed.
B. a person not competent to make a decision is admitted by the family or health care proxy:
This is typically a substituted decision, but not the legal basis for involuntary admission, which requires meeting legal criteria like dangerousness.
C. a person exhibiting behavior that is dangerous to themself or others is compelled into treatment regardless of their own desires:
Involuntary admission is based on risk of harm to self or others or inability to care for oneself due to mental illness.
D. a mother wants to admit her child for a fever and the doctor does not want the child admitted:
This is unrelated to mental health or involuntary psychiatric admission and refers instead to a disagreement over general medical care.
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.
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