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 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.

A. the client feels vulnerable to stigma B. young adults tend to use manipulation C. this is a standard assessment D. the client lives with extended family

Correct Answer is C

Explanation

A. the client feels vulnerable to stigma: While stigma can prevent clients from reporting suicidal thoughts, this is not the primary reason for initiating a suicide risk assessment.

B. young adults tend to use manipulation: Assuming that young adults manipulate their symptoms is not a valid reason for initiating a suicide risk assessment. This response is inappropriate and can harm the therapeutic relationship.

C. this is a standard assessment: A suicide risk assessment is a standard part of care for clients with depression and thoughts of hopelessness, even if suicidal ideation is not explicitly reported. This ensures comprehensive evaluation and appropriate intervention.

D. the client lives with extended family: The living situation may influence the support system, but it is not the primary reason to initiate a suicide risk assessment.

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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

A nurse is caring for a client who has AIDS and anorexia. Which of the following actions should the nurse take to increase the client's body weight?

Correct Answer is D

Explanation

Correct Answer is C

Explanation

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