A nurse in an acute care mental health facility is sitting with a client who has schizophrenia. The client whispers to the nurse, "I'm being kept in this prison against my will. Please try to get me out." Which of the following responses should the nurse make?

"We are here to help you and give you the care that you need right now."

"Do you feel that you don't belong here?"

"Try to take some deep breaths, and I'm sure you'll feel better."

"Why do you feel that you need to leave?"

Answer and Explanation

The Correct Answer is A

Choice A reason: This response is empathetic and reassuring, affirming the nurse's role in providing care and support, which is essential in managing patients with schizophrenia who may experience feelings of paranoia or imprisonment.

Choice B reason: Asking if the patient feels they don't belong could reinforce feelings of alienation or paranoia. It's important to provide reassurance rather than question their sense of belonging.

Choice C reason: While deep breathing can be a calming technique, assuring the patient they will feel better may not address their immediate concerns or the reality of their feelings.

Choice D reason: Asking why they feel the need to leave could challenge the patient's experience and potentially escalate their distress. It's important to validate their feelings and provide reassurance.

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Correct Answer is A

Explanation

Choice A reason: This response is calming and supportive. It addresses Mr. L's immediate distress by providing reassurance and a directive that can help him manage his panic, which is essential in a situation where a patient is experiencing extreme anxiety.

Choice B reason: While taking vital signs is an important step, it should not be the first response. The priority is to address the patient's acute distress and provide reassurance.

Choice C reason: This response minimizes the patient's feelings and does not address his immediate fear or offer any comfort or support.

Choice D reason: Asking why he thinks he's having a heart attack could increase his anxiety. It's important to first calm the patient before attempting to rationalize the situation.

A. Provision of home care. B. Decision for surgery until transfer to surgery. C. Admission to PACU until recovery. D. Transfer to surgery until transfer to PACU.

Correct Answer is C

Explanation

Choice A reason: Provision of home care is not part of the immediate postoperative phase described during preoperative teaching.

Choice B reason: The decision for surgery until transfer to surgery is part of the preoperative phase, not the postoperative phase.

Choice C reason: Admission to the Post Anesthesia Care Unit (PACU) until recovery is the correct description of the postoperative phase, where the patient is monitored as they recover from anesthesia.

Choice D reason: Transfer to surgery until transfer to PACU describes the transition from preoperative to intraoperative phases, not the postoperative phase.

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A nurse in an acute care mental health facility is sitting with a client who has schizophrenia. The client whispers to the nurse, "I'm being kept in this prison against my will. Please try to get me out." Which of the following responses should the nurse make?

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Naxlex Comprehensive Predictor Exams

Mr. L, who has a severe fear of needles, is hospitalized on your medical unit. The laboratory technician enters to draw blood for the routine CBC, and Mr. L begins to cry out, "Get away from me! I can't breathe! I'm having a heart attack!" What should be your first response to Mr. L?

Correct Answer is A

Explanation

Which of these would the nurse state to describe the postoperative phase of surgery to the patient during preoperative teaching?

Correct Answer is C

Explanation

Melva is scheduled for an elective surgery. The surgeon comes to the preoperative area to review the surgical procedure with her. Alternatives are discussed, along with the benefits and risks associated with the surgery. Melva says she understands everything. This is:

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