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 D

Explanation

A. While the medication history can be relevant, it is not the most immediate assessment needed to address the confusion and possible infection.

B. The amount of serous drainage is important for wound assessment but does not directly address the cause of confusion.

C. Urinary output is useful for evaluating kidney function but may not be directly related to the client’s confusion and wound.

D. The white blood cell count is crucial for identifying an infection or inflammatory response, which could be related to both the confusion and the wound.

A. Assist the spouse and carefully give the client small sips of water. B. Give the spouse a straw to help facilitate the client's drinking. C. Obtain thickening powder before providing any more fluids. D. Ask the spouse to stop and assess the client's swallowing reflex.

Correct Answer is D

Explanation

A. Assisting with giving sips of water could pose a choking risk if the client's swallowing ability is impaired.

B. Using a straw could increase the risk of aspiration for a client with swallowing difficulties.

C. Obtaining thickening powder might be necessary, but first the nurse must assess the client's ability to swallow safely.

D. Assessing the client's swallowing reflex is the priority to ensure safe swallowing and prevent aspiration.

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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

An older adult client is brought to the clinic for Increased confusion over the past three days and presents with a draining wound on the right leg. Which assessment is most important for the nurse to obtain?

Correct Answer is D

Explanation

Correct Answer is D

Explanation

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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?

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