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 C

Explanation

A. Encouraging physical activity, like a daily walk, is a positive way to support the client’s mental health
and can help with symptoms of depression.
B. Setting timers for medications and meals is a helpful strategy to ensure the client adheres to the prescribed treatment plan.
C. Letting the client have complete freedom without offering support or asking questions is a risky approach. The nurse should encourage family involvement and monitoring, as clients recovering from a suicide attempt need continued emotional support and guidance.
D. Engaging with the client about their feelings and daily goals can help maintain communication and provide emotional support.

A. Communicate to the client that it is acceptable to cry. B. Determine the client's stage of grief. C. Encourage the client to express feelings openly, D. Enable the client to obtain spiritual support.

Correct Answer is B

Explanation

A. While crying may be a normal expression of grief, determining the client’s stage of grief is more important for assessing the client’s emotional needs.
B. Determining the client’s stage of grief is the first step to understanding the client's emotional state
and providing appropriate support.
C. Encouraging expression is important, but first, understanding the client’s grief stage will guide the
intervention.
D. Spiritual support is valuable, but first, understanding the client's emotional response is necessary before offering this type of assistance.

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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

The nurse is teaching the family of a client about the signs and symptoms of major depression prior to the discharge of their loved one from an inpatient stay after a suicide attempt. Which statement by a family member warrants further education by the nurse?

Correct Answer is C

Explanation

A nurse is caring for a client who has major depressive disorder and has experienced a recent loss. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

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?

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