The nurse must give 25 micrograms of fentanyl IVP X1 dose. Fentanyl is available in an ampule 100 micrograms per 2m How many mL will the nurse give for the correct dose?

round to the nearest tenth. Use a preceding zero if necessary. Do not use trailing zeros.

Choice A Reason:

While this response attempts to offer support, it makes an assumption about the mother’s understanding without addressing the client’s feelings directly. Therapeutic communication should focus on validating the client’s emotions and encouraging them to express their thoughts and feelings. This response might not fully acknowledge the client’s distress.

Choice B Reason:

This response normalizes the client’s feelings, which can be helpful, but it does not directly address the client’s specific concern. While it is important to reassure the client that their feelings are common, the response should also validate their individual experience and encourage further discussion.

Choice C Reason:

Encouraging the client to talk to their mother is a proactive suggestion, but it may not be the most therapeutic initial response. The client might not be ready to take that step, and the nurse should first focus on understanding and validating the client’s feelings before suggesting actions. This response could be more appropriate as a follow-up after the client’s feelings have been explored.

Choice D Reason:

This response is the most therapeutic because it uses reflective listening to validate the client’s feelings. By restating what the client has expressed, the nurse shows empathy and encourages the client to explore their emotions further. This technique helps the client feel heard and understood, which is crucial in therapeutic communication.

Choice A Reason:

Ask open-ended questions.

While asking open-ended questions can be useful in many therapeutic settings, it may not be the best approach when dealing with delusional clients. Open-ended questions can sometimes lead to more elaborate delusional thinking and may not help in grounding the client in reality. Instead, focusing on the present moment and concrete reality can be more effective in managing delusions.

Choice B Reason:

Focus on what is happening in the here and now.

This is the correct response. Focusing on the present moment helps to ground the client in reality and can reduce the intensity of delusional thoughts. By directing the client’s attention to their immediate environment and current activities, the nurse can help the client stay connected to reality and reduce the impact of their delusions.

Choice C Reason:

Assume knowledge of what is meant when the client talks about “they.”

Assuming knowledge of what the client means when they refer to “they” can reinforce delusional thinking. It is important for the nurse to clarify and understand the client’s perspective without validating the delusion. This approach helps maintain a therapeutic relationship while not reinforcing false beliefs.

Choice D Reason:

Limit contact to one or two short interactions daily.

Limiting contact to one or two short interactions daily is not an effective strategy for managing delusions. Clients with delusions often need consistent and supportive interactions to help them stay grounded in reality. Frequent, brief interactions can provide the necessary support and reassurance without overwhelming the client.