A nurse is receiving a client with a radioactive implant for the treatment of cervical cancer. What is the nurse's best action?

Place the client in a private room.

Place a chair next to the bed to allow the spouse to sit.

Have visitors wear dosimeters for safety.

Allow visitors to telephone only.

Answer and Explanation

The Correct Answer is A

A. Place the client in a private room. This is the correct action because clients with radioactive implants need to be isolated to minimize radiation exposure to others.

B. Place a chair next to the bed to allow the spouse to sit. While emotional support is important, prolonged close contact with someone who has a radioactive implant is not recommended due to the risk of radiation exposure.

C. Have visitors wear dosimeters for safety. While this is a good safety measure, the primary concern is limiting visitors and ensuring the client is in a private room to minimize exposure.

D. Allow visitors to telephone only. While telephone communication can be safe and supportive, the best initial action is to place the client in a private room to control radiation exposure.

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Correct Answer is D

Explanation

A. "Are you frightened?" This response is empathetic but may inadvertently reinforce the client's delusional thinking by focusing on the fear rather than addressing the delusion.

B. "You know I'm not following you." This response directly challenges the client's delusion, which could provoke defensiveness and escalate the situation.

C. "You'll have to go into seclusion if you continue to threaten me." This response is confrontational and may escalate the situation further by implying a threat, which could increase the client's fear and anger.

D. "I'm sorry if I frightened you. I was returning to the nurses' station after going out for lunch." This response acknowledges the client's feelings without reinforcing the delusion and provides a simple, non-threatening explanation for the nurse's actions. It helps de-escalate the situation by maintaining a calm, non-confrontational tone.

A. Generalized anxiety disorder B. Posttraumatic stress disorder C. Obsessive-compulsive disorder D. Social phobia

Correct Answer is B

Explanation

A. Generalized anxiety disorder: Generalized anxiety disorder involves persistent and excessive worry, but it does not typically present with the specific symptoms of nightmares and flashbacks related to trauma.

B. Posttraumatic stress disorder: PTSD is characterized by symptoms such as nightmares, flashbacks, and difficulty sleeping, especially following exposure to traumatic events. This fits the soldier’s presentation.

C. Obsessive-compulsive disorder: OCD involves recurrent, intrusive thoughts (obsessions) and/or repetitive behaviors (compulsions). The symptoms described do not align with OCD but rather with trauma-related symptoms.

D. Social phobia: Social phobia involves intense fear of social situations, not the trauma-related symptoms described. It is less relevant to the soldier’s experience of nightmares and flashbacks.

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A nurse is receiving a client with a radioactive implant for the treatment of cervical cancer. What is the nurse's best action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

As a nurse approaches the nurses' station, a client diagnosed with a delusional disorder raises his voice and says, "You're following me. What do you want?" To prevent escalating fear and anger, the nurse takes a nonthreatening posture and makes which response in a calm voice?

Correct Answer is D

Explanation

A soldier has been back from Iraq for two weeks. He is being seen in the outpatient mental health clinic due to complaints of inability to sleep, nightmares, and flashbacks. The nurse would expect the client to be diagnosed with which of the following?

Correct Answer is B

Explanation

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