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?

"Are you frightened?"

"You know I'm not following you."

"You'll have to go into seclusion if you continue to threaten me."

"I'm sorry if I frightened you. I was returning to the nurses' station after going out for lunch."

Answer and Explanation

The Correct Answer is D

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.

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Correct Answer is B

Explanation

A. "Do you go by he, she, or they?" This question is direct and acknowledges the importance of pronouns, but it might be better phrased to be more open-ended and respectful.

B. "What pronouns do you go by?" This is the most respectful and open-ended approach, allowing the client to express their preferred pronouns without making assumptions. It demonstrates a clear understanding of the importance of gender identity and respects the client's autonomy.

C. "What led to this hospital admission?" While this question is relevant to the client’s care, it does not address the client's gender identity directly, which is crucial in this context.

D. "What brings you in today?" Similar to option C, this question focuses on the reason for the hospital visit but does not address the client's gender identity, missing an opportunity to show respect for their identity.

A. Leave the client alone during a new experience. B. Give support in nonverbal ways. C. Be available and attentive to the client's requirements. D. Give detailed explanations and do not repeat them frequently.

Correct Answer is C

Explanation

A. Leave the client alone during a new experience. Leaving an anxious client alone during a new experience may increase their anxiety and hinder the development of trust. Clients need support and reassurance during unfamiliar situations.

B. Give support in nonverbal ways. Nonverbal support, such as a calm presence or gentle touch, can be comforting and help build trust without overwhelming the client with too much verbal communication.

C. Be available and attentive to the client's requirements. Being available and attentive shows the client that the nurse is reliable and responsive to their needs, which helps build trust in the therapeutic relationship.

D. Give detailed explanations and do not repeat them frequently. While providing detailed explanations is important, failing to repeat them as needed could leave the client feeling unsupported or confused, especially if they need reassurance.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An adult client was born as a female gender but has a male gender identity. Which statement by the nurse demonstrates a therapeutic approach of respecting the client's gender identity?

Correct Answer is B

Explanation

Building trust is especially critical to developing a therapeutic relationship with an anxious client. Which of the following interventions contributes to this trust?

Correct Answer is C

Explanation

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