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 C
Explanation
A. hallucinogens:
These primarily affect perception and cognition, not respiratory depression.
B. PCP:
PCP (phencyclidine) is a dissociative anesthetic that can cause agitation, hallucinations, or psychosis, but it doesn't typically cause respiratory depression.
C. opiates:
Opiates (e.g., heroin, morphine) depress the central nervous system, particularly the brain's respiratory center, which can lead to respiratory failure and death.
D. cocaine:
Cocaine is a stimulant that can cause cardiac issues or respiratory distress via vasoconstriction, but it doesn't suppress the respiratory drive like opiates do.
Correct Answer is B
Explanation
A. Risperidone
An antipsychotic used for schizophrenia or bipolar disorder-not used for opioid withdrawal.
B. Methadone
Methadone is a long-acting opioid agonist used in medication-assisted treatment for opioid use disorder and managing withdrawal symptoms safely.
C. Disulfiram
Used for alcohol dependence, not opioids. Causes adverse effects when alcohol is consumed.
D. Lithium carbonate
A mood stabilizer used primarily in bipolar disorder, not effective for opioid withdrawal.
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