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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Tremors, headache, flushed face, and hallucinations: Acute alcohol withdrawal commonly presents with tremors, headache, flushed face, and hallucinations. These symptoms are characteristic of withdrawal syndrome and are important to monitor.

B. Psychomotor hypoactivity, hypotension, and increased appetite: Psychomotor hypoactivity and increased appetite are not typical symptoms of acute alcohol withdrawal. Hypotension may occur, but it is not the most prominent symptom.

C. Hypomania, bradycardia, and generalized seizures: Hypomania and bradycardia are not typical for alcohol withdrawal. Generalized seizures can occur in severe cases of withdrawal (delirium tremens), but hypomania is not a common symptom.

D. Anhidrosis, hypotonicity, and delusions: Anhidrosis (lack of sweating) and hypotonicity (decreased muscle tone) are not typical for alcohol withdrawal. Delusions may occur but are not the primary symptoms.

A. "It will not produce sedation like benzodiazepines" B. "It produces anticonvulsant action to prevent convulsions." C. "It produces muscle relaxant effects to decrease back pain." D. "It provides you with a sleep additive to decrease insomnia."

Correct Answer is A

Explanation

A. "It will not produce sedation like benzodiazepines." Buspirone is a non-sedative anxiolytic, making it safer for long-term use compared to benzodiazepines, which can cause sedation and other CNS depressant effects. This is the best response as it directly addresses the patient's concern about safety.

B. "It produces anticonvulsant action to prevent convulsions." Buspirone does not have anticonvulsant properties, and this response does not address the patient’s question about safety compared to benzodiazepines.

C. "It produces muscle relaxant effects to decrease back pain." Buspirone does not have muscle relaxant effects, and this response does not directly answer the patient’s concern about the safety of the medication.

D. "It provides you with a sleep additive to decrease insomnia." Buspirone does not have significant sedative or hypnotic effects, making this response incorrect.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

A 51-year-old male has been admitted to the detoxification unit with acute symptoms of alcohol withdrawal. Nursing assessment is likely to reveal what?

Correct Answer is A

Explanation

A patient's medication regimen for treatment of anxiety has been changed from a benzodiazepine to buspirone (BuSpar). The patient asks the nurse what makes this medication safer than the benzodiazepine he has taken. What is the nurse's best response?

Correct Answer is A

Explanation

A client received chemotherapy 24 hours ago. Which precautions are necessary when caring for the client?

A nurse is assisting in preparing a presentation at a community center about systemic lupus erythematosus (SLE). The nurse should identify which of the following groups as having the highest risk for developing this disorder?

Which of the following assessment findings is observed in a client with opiate use?

A nurse is caring for a client who has multiple myeloma and has a WBC count of 2,200/mm3. Which of the following food items brought by the family should the nurse prohibit from being given to the client?

When administering an antipsychotic medication to a client diagnosed with schizophrenia, which action would be most appropriate for the nurse to include in the client's plan of care? Select all that apply.

A client with schizophrenia is reluctant to take his prescribed oral medication. The most therapeutic response by the nurse to this refusal is:

The nurse is caring for a client with Wernicke encephalopathy. The nurse determines that teaching has been effective when the client makes which statement?

The nurse is aware that all the following pharmacological agents are useful in treating anxiety disorders except: