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?"
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E"]
Explanation
Choice A reason: Making decisions for the patient can undermine their autonomy and is not therapeutic in treating Paranoid Personality Disorder.
Choice B reason: Avoiding situations that the patient may perceive as demeaning is actually an appropriate intervention, as it helps to build trust and rapport.
Choice C reason: Greatly limiting social contact is not recommended as it can increase feelings of isolation and paranoia.
Choice D reason: Avoiding discussion of the treatment plan is not appropriate; patients should be involved in their care decisions to the greatest extent possible.
Choice E reason: Maintaining honest, open communication is an appropriate and necessary intervention for building a therapeutic relationship with a patient with Paranoid Personality Disorder.
Correct Answer is B
Explanation
Choice A reason: While patients with HbA1c levels below 6% are generally considered to have good glycemic control, this does not guarantee they will be free from complications.
Choice B reason: Diabetes complications often involve vascular issues, affecting both large (macrovascular) and small (microvascular) blood vessels, leading to a range of complications such as cardiovascular disease and neuropathy.
Choice C reason: Chronic hypoglycemia can lead to various health issues, but it is not typically classified as a long-term complication of diabetes. Instead, it is a risk associated with diabetes management, particularly with insulin use.
Choice D reason: Both Type 1 and Type 2 diabetics are at risk for complications. Tight glycemic control can reduce the risk, but it does not eliminate it, and Type 1 diabetics are not necessarily at the greatest risk.
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