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."
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Offer the client fluids with meals. Offering fluids with meals may decrease the client's appetite by creating a sense of fullness, which could further reduce calorie intake and not aid in weight gain.
B. Increase fiber in the client's diet. While fiber is important for digestive health, it may also contribute to a feeling of fullness and might not directly help in increasing body weight in clients with anorexia.
C. Encourage the client to eat less protein. Protein is essential for maintaining muscle mass and overall health, especially in clients with AIDS. Reducing protein intake would not be beneficial for weight gain or health maintenance.
D. Provide supplemental vitamins and supplemental nutrition. Offering supplemental nutrition and vitamins can help increase caloric intake and ensure that the client receives essential nutrients to support weight gain and overall health. This is the most appropriate action to help increase the client's body weight.
Correct Answer is A
Explanation
A. Repetitive thoughts and recurring impulses: OCD is characterized by obsessions (repetitive, intrusive thoughts) and compulsions (recurring impulses or behaviours performed to reduce anxiety). This choice best describes the core features of OCD.
B. Physical signs and symptoms with no physiologic cause: This description does not accurately describe OCD. While OCD symptoms are distressing and impairing, they are not typically categorized as having no physiologic cause.
C. Apprehension: Apprehension or general anxiety can be associated with many mental health disorders, but it is not specific to OCD, which is more about the presence of obsessions and compulsions rather than generalized apprehension.
D. Inability to concentrate: While inability to concentrate can be a symptom in various mental health disorders, it is not specific to OCD. OCD is more specifically characterized by repetitive thoughts and actions.
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