The nurse is caring for a client who has a history of experiencing delusions. The client describes singing in a concert in the afternoon for thousands of people. Which action should the nurse take?

Attempt to comfort the client by agreeing with the delusions and ask open ended questions.

Disagree with the statement and set clear limits on talking about it.

Immediately inform the provider that the client is experiencing a delusional episode.

Present a personal perception of reality in a non-confrontational manner.

Answer and Explanation

The Correct Answer is D

A. Agreeing with the delusions can reinforce the false beliefs and is not an effective therapeutic approach.

B. Disagreeing and setting limits may escalate the client's anxiety or agitation and does not address the delusion in a therapeutic manner.

C. While informing the provider is important, the immediate action should focus on therapeutic communication with the client.

D. Presenting a personal perception of reality in a non-confrontational manner helps the client to gently challenge their delusion and encourages a more grounded conversation.

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Correct Answer is C

Explanation

A. The administration of intramuscular injections can be handled by a practical nurse.

B. Fatigue management and monitoring during radiation treatments can also be managed by a practical nurse.

C. The decision to switch to palliative care involves complex conversations and ethical considerations, requiring the assessment and intervention skills of an RN.

D. Post-biopsy care and monitoring, especially with a benign diagnosis, can be managed by a practical nurse.

A. Rise slowly when getting up. B. Take medication in the morning. C. Erectile dysfunction is common with the prescribed medication. D. Medication may cause the heart to race. E. Ibuprofen should be taken 2 hours before taking medication. F. Symptoms should be resolved within 1 week. G. Ensure cane is used when ambulating.

Correct Answer is ["A","B","C","G"]

Explanation

A. Rise slowly when getting up: Finasteride and tamsulosin can cause orthostatic hypotension, making it important for the client to change positions slowly to prevent dizziness and falls.

B. Take medication in the morning: Tamsulosin is typically taken once daily, 30 minutes after the same meal each day, often recommended in the morning to align with the daily routine and reduce the likelihood of missing doses.

C. Erectile dysfunction is common with the prescribed medication: Finasteride may cause sexual side effects such as erectile dysfunction, decreased libido, and ejaculation disorders. It is important to inform the client of these potential side effects.

D. Medication may cause the heart to race: This is not a common side effect of finasteride or tamsulosin. Tamsulosin can cause hypotension, but it does not typically cause tachycardia.

E. Ibuprofen should be taken 2 hours before taking medication: There is no specific interaction that requires timing ibuprofen around these medications.

F. Symptoms should be resolved within 1 week: Improvement in symptoms of benign prostatic hyperplasia (BPH) with medications like finasteride and tamsulosin typically takes several weeks to months, not just one week.

G. Ensure cane is used when ambulating: Given the client's use of a cane and the potential for orthostatic hypotension, it is crucial to reinforce the use of the cane to prevent falls and ensure safe ambulation.

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The nurse is caring for a client who has a history of experiencing delusions. The client describes singing in a concert in the afternoon for thousands of people. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which client should the charge nurse on the oncology unit assign to an RN, rather than a practical nurse (PN)?

Correct Answer is C

Explanation

Exhibits The nurse reviews the healthcare provider's orders. Select the 4 things the nurse should educate the client about taking his medication.

Correct Answer is ["A","B","C","G"]

Explanation

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