A nurse is caring for a client who lost all his possessions in a house fire and states, "I have no idea what I am going to do. I cannot think right now." Which of the following actions should the nurse take?
Identify other housing options and sources of transportation.
Notify the facility chaplain to request scheduling an appointment.
Confirm that everything will be all right because belongings can be replaced.
Maintain eye contact with the client and summarize the client's feelings.
The Correct Answer is D
Answer is d. Maintain eye contact with the client and summarize the client’s feelings.
a. Identify other housing options and sources of transportation: While it is essential to address practical needs such as housing and transportation for clients who have experienced a crisis like a house fire, it is not the immediate priority when the client is in acute emotional distress. In this scenario, the client is expressing emotional distress and may not be ready to focus on practical solutions. Therefore, addressing the client's emotional needs should take precedence over addressing practical concerns.
b. Notify the facility chaplain to request scheduling an appointment: While spiritual support can be beneficial for individuals coping with trauma or loss, it should not be the immediate response when a client is in acute emotional distress. While the chaplain's support may be sought later as part of the client's holistic care, it should not precede addressing the client's immediate emotional needs.
c. Confirm that everything will be all right because belongings can be replaced: This option is incorrect because it offers false reassurance and dismisses the client's feelings about their loss. While it is true that belongings can be replaced, the emotional impact of losing possessions, especially in a traumatic event like a house fire, should not be trivialized. The client's feelings of distress and uncertainty are valid and should be acknowledged and addressed by the nurse.
d. Maintain eye contact with the client and summarize the client’s feelings: Correct. This action demonstrates therapeutic communication, which is crucial in providing an atmosphere of support and safety for the client. Maintaining eye contact shows empathy, support, and advocacy, indicating to the client that their feelings are being heard and validated. Summarizing the client's feelings allows the nurse to demonstrate active listening and understanding, fostering trust and rapport between the nurse and client. By prioritizing the client's emotional needs, the nurse can help the client begin to process their feelings and move towards coping and problem-solving.
In summary, the correct answer is d because maintaining eye contact with the client and summarizing their feelings demonstrates therapeutic communication, which is essential in providing support and validation for the client's emotional distress. This approach allows the nurse to establish rapport and trust with the client, facilitating further therapeutic interventions and support.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
Choice A rationale:
Lithium is a mood stabilizer commonly used to treat bipolar disorder. It helps to regulate mood swings, prevent manic episodes, and reduce the risk of depressive episodes.
Choice B rationale:
Donepezil is not used to treat bipolar disorder. It is an acetylcholinesterase inhibitor primarily used to treat symptoms of Alzheimer's disease.
Choice C rationale:
Valproate (Depakote) is another mood stabilizer used in the treatment of bipolar disorder. It can help manage both manic and depressive episodes, as well as prevent future mood swings.
Choice D rationale:
Carbamazepine (Tegretol) is an anticonvulsant medication that also has mood-stabilizing properties. It is often prescribed for individuals with bipolar disorder, especially those who do not respond well to lithium.
Choice E rationale:
Paroxetine (Paxil) is a selective serotonin reuptake inhibitor (SSRI) commonly used to treat depression and anxiety disorders. It is not a primary medication choice for bipolar disorder.
Correct Answer is B
Explanation
The correct answer is choice B. Erotomanic.
Choice A rationale:
Persecution. Persecutory delusions involve the belief that one is being targeted, harmed, or conspired against by others. This choice is not applicable in this scenario because the client is not expressing fear or belief that they are being persecuted.
Choice B rationale:
Erotomanic. Erotomanic delusions involve the false belief that someone, often of higher social status, is in love with the individual. In this case, the client's statement about being engaged to the Prince of England suggests an erotomanic delusion. The client is holding a grandiose belief that they are romantically involved with someone of prominence.
Choice C rationale:
Somatic. Somatic delusions involve the belief that there is something physically wrong with the individual's body. These delusions often manifest as the belief in having an illness or defect that is not actually present. The client's statement does not revolve around physical health or bodily concerns, making somatic delusion an unlikely option.
Choice D rationale:
Control. Control delusions involve the belief that one's thoughts, feelings, or actions are being controlled by external forces. This choice is not applicable in this scenario, as the client's statement does not indicate any perceived loss of control over their thoughts or actions.
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