A nurse is caring for a client who has paranoid schizophrenia and believes that they are being followed by FBI agents who are pretending to be psychiatric staff.
Which of the following responses should the nurse make?
The psychiatric staff is not FBI. They are here to help you.
This must be very frightening for you. Let's talk more about it.
What makes you think the staff is following you?
Why do you feel the staff is the FBI?
The Correct Answer is B
b. This must be very frightening for you. Let's talk more about it.
It is important for the nurse to acknowledge the client's fears and show empathy towards them. By saying "This must be very frightening for you," the nurse validates the client's feelings and shows that they are being heard.
Additionally, by suggesting that they talk more about it, the nurse can work towards building a therapeutic relationship with the client and gain more insight into their thought processes.
The other options are not appropriate because:
a. The nurse should not deny the client's beliefs or try to convince them that they are wrong. This can cause
the client to feel invalidated and may make them less likely to trust the nurse.
c. While it is important to understand the client's perspective, this question may come off as confrontational and accusatory.
d. Similarly, this question may be perceived as confrontational and may make the client defensive. It is important to approach the client with empathy and understanding rather than skepticism.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
An incident report is a formal document used to report any unexpected or adverse events that occur during patient care. In this case, the administration of an incorrect dosage is an incident that should be documented in the incident report. The incident report serves as a record of the event and helps to ensure that appropriate follow-up actions are taken to prevent similar incidents in the future. It is important to note that an incident report is not part of the client's permanent medical record and is kept separate from other documentation.
The provider's progress notes, nursing care plan, and controlled substance inventory record are not appropriate locations to document this specific incident. The provider's progress notes are typically used to document the client's medical history, examination findings, treatment plans, and progress. The nursing care plan is a document that outlines the client's nursing diagnoses, goals, and interventions. The controlled substance inventory record is used to track and document the dispensing and administration of controlled substances, but it does not typically include incident reporting.
Correct Answer is D
Explanation
Informed consent is a critical step before any invasive procedure, including an EGD. The nurse should confirm that the client has received the necessary information about the procedure, its risks and benefits, and has given their consent voluntarily. This ensures that the client understands the procedure and its implications, making it an essential part of their rights and safety.
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