Which of the following nursing strategies would be most appropriate when caring for an individual who is delusional?

Ask open-ended questions.

Focus on what is happening in the here and now.

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

Limit contact to one or two short interactions daily.

Answer and Explanation

The Correct Answer is B

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.

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Free Nursing Study Resources

Correct Answer is ["125"]

Explanation

To calculate the infusion rate in drops per minute:

Identify the total volume to be infused: 125 mL
Identify the total time for infusion: 1 hour (which is 60 minutes)
Identify the drop factor: 60 gtts/mL

Step 1: Calculate the infusion rate in mL per minute.

Volume (mL) ÷ Time (minutes)
125 mL ÷ 60 minutes = 2.0833 mL per minute

Step 2: Calculate the infusion rate in drops per minute.

Infusion rate (mL per minute) × Drop factor (gtts/mL)
2.0833 mL per minute × 60 gtts/mL = 125 gtts per minute

The drug will infuse at 125 drops per minute.

A. Encourage social interaction. B. Discuss the bizarre behavior. C. Give the client information about her illness. D. Provide a safe environment.

Correct Answer is D

Explanation

Choice A Reason:

Encouraging social interaction might not be appropriate in this situation. The client’s bizarre behavior is already causing distress to others, and encouraging more interaction could exacerbate the problem. The priority should be to address the immediate safety and well-being of both the client and others. Once the client is in a safe environment, social interaction can be encouraged in a controlled and therapeutic manner.

Choice B Reason:

Discussing the bizarre behavior with the client might not be effective in the moment, especially if the client is not in a state to understand or engage in such a discussion. The primary focus should be on ensuring safety and stability before addressing specific behaviors. Once the client is calm and in a safe environment, discussions about behavior can be more productive.

Choice C Reason:

Providing information about the client’s illness is important for long-term management and understanding, but it is not the immediate priority in this situation. The client’s current state requires immediate intervention to ensure safety. Education about the illness can be provided once the client is stabilized and in a better position to comprehend the information.

Choice D Reason:

Providing a safe environment is the most immediate and crucial priority. The client’s behavior is not only distressing to others but could also pose a risk to herself and others. Ensuring the client is in a safe, controlled environment helps to prevent harm and allows for further assessment and appropriate interventions. Safety is always the first priority in managing acute behavioral disturbances.

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Which of the following nursing strategies would be most appropriate when caring for an individual who is delusional?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An IV infusion of 125 mL of a GI prokinetic agent is ordered to be given over 1 hour. The nurse will use a microdrip infusion set (60 gtts/mL). How many drops per minute will the drug infuse at the proper rate? Use a preceding zero if necessary. Do not use trailing zeros.

Correct Answer is ["125"]

Explanation

The nurse notices a client wandering in the hospital hall giggling, with bizarre behavior that is annoying and frightening other clients. A priority in caring for her is to:

Correct Answer is D

Explanation

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