A nurse is caring for a client who has schizophrenia. The client tells the nurse, "Government agents are out to get me." Which of the following responses should the nurse make?

"You will be okay."

"Feelings of persecution are normal with your condition."

"It must be frightening to believe that someone is after you."

"Let me check to see if it's time to take your medication."

Answer and Explanation

The Correct Answer is C

A. Incorrect. This response dismisses the client's concerns and does not acknowledge the distress the client may be experiencing.
B. Incorrect. While it's true that paranoia is a common symptom of schizophrenia, stating that it is "normal" may invalidate the client's feelings and does not address the underlying distress. C. Correct. This response validates the client's feelings and demonstrates empathy by acknowledging the distress associated with the belief that government agents are after them.
D. Incorrect. While medication management is important in the treatment of schizophrenia, this response does not address the client's immediate concerns or validate their feelings of persecution.

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Correct Answer is D

Explanation

A client who has a head injury and whose pupils are fixed and dilated: This client likely has a severe head injury with signs of increased intracranial pressure, which requires urgent intervention. However, airway and breathing take precedence over neurological status in triage. B. A client who has a dislocated shoulder and reports a pain level of 8 on a scale from 0 to 10: While this client is in pain, dislocated shoulder is not immediately life-threatening in the context of a mass casualty situation.
C. A client who has a 20.3-cm (8-in) scalp laceration with intermittent bleeding: Although this client has a significant laceration, it is not immediately life-threatening compared to compromised breathing.
D. A client who has diminished breath sounds and paradoxical chest movement: This client is likely experiencing a tension pneumothorax, a life-threatening condition that requires immediate intervention to decompress the chest and restore normal breathing.

A. Sims B. Prone C. Supine D. Orthopneic

Correct Answer is C

Explanation

A. The Sims position is lying on the left side with the right knee and thigh drawn up with the left arm placed along the back. This position is typically used for rectal examinations and enemas, not for administering nasal drops.
B. The prone position is lying face down. This position is not suitable for administering nasal drops as it can be uncomfortable and may obstruct proper administration.
C. The supine position is lying flat on the back with the face upward. This position is ideal for administering nasal drops as it allows for easy access to the nostrils and facilitates proper instillation of the medication.
D. The orthopneic position is sitting upright and leaning forward, often with the arms supported on a table or pillows. This position is sometimes used by patients with respiratory distress but is not typically recommended for administering nasal drops.

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A nurse is caring for a client who has schizophrenia. The client tells the nurse, "Government agents are out to get me." Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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