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. Medication compliance is important but does not address the most immediate concerns for individuals with borderline personality disorder, such as self-harm.
B. Awareness of the potential for self-harm is the priority because individuals with borderline personality disorder often engage in self-destructive behaviors.
C. Resources for group therapy in the community are valuable but secondary to ensuring immediate safety.
D. Insurance coverage is important but not urgent compared to the immediate need for safety and awareness of self-harm risks.

A. Preoccupied with maintaining order by following rigid rules B. Believes his achievements are superior to others C. Requires excessive amount of advice before making decisions D. Uses physical appearance to make others take notice of him

Correct Answer is A

Explanation

A. Obsessive-compulsive personality disorder is characterized by a preoccupation with orderliness, perfectionism, and a need for control.
B. Believing achievements are superior is a hallmark of narcissistic personality disorder, not obsessive- compulsive personality disorder.
C. Requiring excessive advice is more typical of dependent personality disorder.
D. Using physical appearance to gain attention is characteristic of histrionic personality disorder.

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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 is reinforcing teaching with the family of a client who has a new diagnosis of borderline personality disorder about the disorder. Which of the following information should be the nurse's priority?

Correct Answer is B

Explanation

A nurse is collecting data from a client who has obsessive-compulsive personality disorder. Which of the following findings should the nurse include?

Correct Answer is A

Explanation

A nurse is collecting data from a client who has bipolar disorder with mania. Which of the following findings is the nurse's priority?

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