A nurse is caring for a client who has schizophrenia. The client exclaims, “Aliens came into my room last night and took a sample of my blood!” Which of the following responses should the nurse make?
“Aliens do not exist.”
“Has your daughter had her baby?”
“Do you mean to say a laboratory technician drew your blood last night?”
“I didn’t see any aliens, but you seem frightened.”
The Correct Answer is D
A: Telling the client that aliens do not exist dismisses their experience and can increase their distress. It is not a therapeutic response.
B: Changing the subject to the client’s daughter is not addressing the client’s immediate concern and can be seen as dismissive.
C: Suggesting that a laboratory technician drew the blood is an attempt to reorient the client to reality, but it may not be effective if the client is deeply entrenched in their delusion.
D: Acknowledging the client’s fear without validating the delusion is a therapeutic response. It shows empathy and provides an opportunity to explore the client’s feelings further.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A: Helping the client identify positive personality traits is important for building self-esteem and motivation for recovery, but it is not the immediate priority during detoxification.
B: Providing for adequate hydration and rest is the priority because it addresses the client’s immediate physical needs. Alcohol withdrawal can cause dehydration and exhaustion, which need to be managed to prevent complications such as seizures and delirium tremens.
C: Educating the client about the consequences of alcohol misuse is essential for long-term recovery but is not the immediate priority during the acute phase of detoxification.
D: Confronting the use of denial and other defense mechanisms is part of the therapeutic process but is not the immediate priority during detoxification. The focus should be on stabilizing the client’s physical condition first.
Correct Answer is C
Explanation
A: Naloxone is used to reverse opioid overdoses, not LSD intoxication.
B: Seclusion and restraint should be used only if the patient poses an immediate threat to themselves or others and other de-escalation techniques have failed.
C: Offering reassurance and emotional support is the primary approach for managing a patient under the influence of LSD. Providing a calm and supportive environment helps reduce anxiety and agitation.
D: Respiratory complications are not typically associated with LSD use. Intubation is not a standard response for LSD intoxication unless there are other complicating factors.
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