A nurse is caring for a client who has delusional behavior. The client states, "I can't go to group today. I am expecting a high level official to visit me!" Which of the following responses should the nurse make?

"Let's walk together to group so we can discuss your concerns."

"I think you should attend group therapy. We will talk about this when you're done."

"I wouldn't worry about that. They will call you back later."

"Why do you think you are getting a visit from someone today?"

Answer and Explanation

The Correct Answer is A

A.   Acknowledge the client’s delusion while gently redirecting them to the necessary activity (group
therapy). This approach maintains engagement without directly confronting the delusion.
B.   Ignoring the delusion and focusing only on group therapy may cause the client to feel unheard or dismissed.
C.   Dismissing the delusion is not therapeutic and could undermine trust.
D.   Asking "why" could challenge the delusion, leading to defensiveness rather than productive conversation.

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Correct Answer is B

Explanation

A. A depressive state may involve feelings of hopelessness, but giving away possessions and saying goodbyes are signs of potential suicidal intent.
B. Suicidal intent is the primary concern in this situation. These behaviors are commonly seen when a client is preparing to end their life.
C. A plan to relocate would not typically involve giving away possessions or saying goodbyes in such a manner.
D. Elopement with a partner is not a typical behavior associated with suicidal intent.

A. Wrap the blood pressure cuff snugly around the arm. B. Center the cuff bladder over the brachial artery. C. Place the client's arm above the level of the heart. D. Check the instrument gauge to ensure the reading starts at zero

Correct Answer is C

Explanation

A. Wrapping the blood pressure cuff snugly around the arm is correct, as the cuff needs to be secure to ensure an accurate reading.
B. Centering the cuff bladder over the brachial artery is correct, as this is necessary for accurate blood pressure measurement.
C. Placing the client's arm above the level of the heart is incorrect. The arm should be at heart level to ensure the accuracy of the reading. If the arm is elevated, it could result in a falsely low reading.
D. Checking the instrument gauge to ensure the reading starts at zero is correct. This step is important to ensure the accuracy of the measurement.

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A nurse is caring for a client who has delusional behavior. The client states, "I can't go to group today. I am expecting a high level official to visit me!" Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse must be alert when a client is giving away possessions, getting his/her life in order, or making vague goodbyes to people. Which of the following should the nurse be concerned about?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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