A nurse is caring for a client who has schizophrenia. The client states, "They lie about me all the time and are trying to poison my food." Which of the following responses should the nurse make?

"You seem to be having some very frightening thoughts."

"Why do you think you are being lied about and poisoned?"

"You are mistaken. Nobody is lying about you or trying to poison you."

"Who is lying about you and trying to poison you?"

Answer and Explanation

The Correct Answer is A

Choice A reason: This response acknowledges the client's feelings without agreeing with the delusion or challenging their reality, which can help in building trust and rapport.

Choice B reason: Asking "Why do you think you are being lied about and poisoned?" could potentially reinforce the delusion and lead the client to further justify their beliefs.

Choice C reason: Directly telling the client they are mistaken can be confrontational and may damage the therapeutic relationship.

Choice D reason: Asking "Who is lying about you and trying to poison you?" can validate the delusion and is not a therapeutic response.

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Correct Answer is C

Explanation

Choice A reason: Direct communication with the surgeon can provide the patient with reassurance and specific information about the surgery, which may alleviate fears.

Choice B reason: Offering spiritual support may be helpful, but it does not directly address the patient's concern about the surgery itself.

Choice C reason: Providing statistics may be reassuring, but it may not fully address the patient's individual fears.

Choice D reason: Recommending analgesics only addresses pain management and not the patient's expressed fear regarding the surgery.

A. Notify the physician. B. Evaluate the distal pulses. C. Have the patient lie in bed with a pillow under the knees. D. Cover the patient with a blanket.

Correct Answer is B

Explanation

Choice A reason: Notifying the physician is important, but it is not the immediate action to take. The nurse should first assess the patient's condition before contacting the physician.

Choice B reason: Evaluating the distal pulses is the correct action because it provides information on the blood flow to the extremities, which is crucial for patients with PAD.

Choice C reason: Having the patient lie in bed with a pillow under the knees is not recommended for PAD patients as it can decrease blood flow to the lower extremities.

Choice D reason: Covering the patient with a blanket may provide comfort, but it does not address the underlying issue of impaired blood flow in PAD.

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A nurse is caring for a client who has schizophrenia. The client states, "They lie about me all the time and are trying to poison my food." Which of the following responses should the nurse make?

Nursing Test Bank

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