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. Instruct to resume regular activities such as driving. It is not safe to instruct the client to resume activities like driving immediately, especially at the beginning of lithium therapy, as lithium can cause side effects that may impair the client's ability to safely perform tasks such as driving.

B. Administer lithium before meals. Lithium is typically taken with food to minimize gastrointestinal upset. Administering it before meals may increase the risk of side effects like nausea.

C. Withhold if serum level is less than 1.5 mEq. Lithium should be withheld if the serum level is above the therapeutic range (typically 0.6–1.2 mEq/L), as higher levels can lead to toxicity. Withholding lithium if the level is less than 1.5 mEq/L is incorrect and could lead to inadequate treatment.

D. Instruct to avoid breastfeeding. Lithium is excreted in breast milk and can pose a risk to the infant, so the client should be advised against breastfeeding while on lithium therapy.

A. Prothrombin level B. Chest x-ray C. Brain CT scan or MRI D. Lumbar puncture

Correct Answer is C

Explanation

A. Prothrombin level: Although checking coagulation levels like prothrombin time may be important, it is not the first-line diagnostic tool for determining the type of stroke (ischemic or hemorrhagic), which is critical for treatment decisions.

B. Chest x-ray: A chest x-ray is not directly related to diagnosing or determining the type of stroke. It may be used for other purposes, such as assessing for respiratory issues, but it is not the priority in stroke diagnosis.

C. Brain CT scan or MRI: A brain CT scan or MRI is the most crucial diagnostic test to perform before initiating treatment for a stroke. This imaging helps differentiate between ischemic and hemorrhagic stroke, guiding the appropriate treatment approach.

D. Lumbar puncture: A lumbar puncture may be used in certain neurological evaluations but is not the first-line test for diagnosing a stroke. It is invasive and not typically performed in the acute setting for stroke evaluation.

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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

Which of the following nursing interventions should a nurse perform when caring for a female client with mood disorder who is prescribed lithium?

Correct Answer is D

Explanation

A client is brought to the emergency department with symptoms of a cerebrovascular accident (CVA). The nurse would anticipate which diagnostic evaluation to be completed prior to initiation of treatment?

Correct Answer is C

Explanation

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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?

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