The nurse is observing the interaction between a mother and schizophrenic son. The son states, "The man visiting me said you went on vacation without me." The mother replied, "There is no man, you are just making that up." When interacting with the mother privately, which reply from the mother would the nurse suggest?
"I am not on vacation. I am here with you."
"How can I go on vacation. I do not have any money."
"Stop saying that. You know better. No one told you that."
"Just forget about that and let's talk about something else."
The Correct Answer is A
A. "I am not on vacation. I am here with you." This response calmly reassures the client by affirming the mother’s presence, which helps address the son’s confusion without directly challenging his perception.
B. "How can I go on vacation? I do not have any money." This response could increase confusion and does not address the son's needs effectively. It could also lead to unnecessary discussions that might not be helpful.
C. "Stop saying that. You know better. No one told you that." This response is dismissive and confrontational, which may exacerbate the son’s distress and could damage the therapeutic relationship.
D. "Just forget about that and let's talk about something else." This response avoids addressing the son’s concerns, which can make him feel dismissed and not listened to, potentially worsening his symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is D
Explanation
A. Grab bars: Grab bars are useful for preventing falls in the bathroom but are unrelated to the client’s atrophy of olfactory organs, which affects the sense of smell.
B. Nonslip mats: Nonslip mats can help prevent falls but are not related to the client’s diminished sense of smell.
C. Baseboard heaters: Baseboard heaters are unrelated to olfactory atrophy and do not address the safety concerns associated with a reduced sense of smell.
D. A smoke detector: A smoke detector is essential for this client because the atrophy of olfactory organs means the client may not be able to detect the smell of smoke, increasing the risk of not noticing a fire.
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