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?"
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Notifying the physician is important, but it is not the immediate action to take. The nurse should first assess the patient's condition before contacting the physician.
Choice B reason: Evaluating the distal pulses is the correct action because it provides information on the blood flow to the extremities, which is crucial for patients with PAD.
Choice C reason: Having the patient lie in bed with a pillow under the knees is not recommended for PAD patients as it can decrease blood flow to the lower extremities.
Choice D reason: Covering the patient with a blanket may provide comfort, but it does not address the underlying issue of impaired blood flow in PAD.
Correct Answer is A
Explanation
Choice A reason: Coughing and deep breathing exercises after surgery are encouraged to prevent atelectasis, which is the collapse of part or (less commonly) all of a lung.
Choice B reason: Induction is not a postoperative complication; it refers to the process of initiating anesthesia.
Choice C reason: Hypothermia is a condition of abnormally low body temperature, not directly prevented by coughing and deep breathing.
Choice D reason: Hematoma, a collection of blood outside of blood vessels, is not prevented by coughing and deep breathing exercises.
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