The nurse is caring for a patient who says, "I have to go to the bank. The voices are telling me to go there." Which of the following responses by the nurse is best?
a. "I want to help you focus away from the voices. I am real, they are not."
b. "I will call you a cab later. Right now, it is time for therapy."
c. "Why do you think the voices are telling you to go to the bank?"
d. "Do you need money?"
ANS: A
A validates the patient's concern without exploring and focusing on the delusion. B does not validate the concern. C encourages the patient to focus on the delusion. D might be appropriate for an elderly person with dementia, but a patient with schizophrenia needs to be brought back to reality.
You might also like to view...
When caring for a client with the nursing diagnosis of Falls, risk for, a priority of nursing care to reduce a successful charge of negligence should the client fall would include which of the following?
1. A friendly relationship with the injured client 2. Documentation demonstrating the standard of care was followed 3. The client recovers fully from the injuries without lasting harm. 4. Promptly informing the family of the client's fall and condition
The nurse gets the hand-off report on four clients. Which client should the nurse assess first?
a. Client with a blood pressure change of 128/74 to 110/88 mm Hg b. Client with oxygen saturation unchanged at 94% c. Client with a pulse change of 100 to 88 beats/min d. Client with urine output of 40 mL/hr for the last 2 hours
Benefits of effective planning include timely accomplishment of higher quality work and the best possible use of capital and human resources. Because planning is essential managers must be able to overcome barriers that impede planning
What is an important point for successful organizational planning? A) The organization can be more effective if movement within it is directed at specified goals and objectives. B) Plans to reach a goal must be rigid and not allow for readjustment as events occur. C) The manager should include in the planning process the leadership people of units that could be affected by the plan. D) A global plan and outline is sufficient to encourage and motivate employees.
A patient has been prescribed all four first-line drugs for tuberculosis (TB). Which laboratory blood value is most important for the nurse to report to the prescriber first?
a. Red blood cells (RBCs) 2.2 million/mm3 b. International normalized ratio 1.6 c. White blood cells 6000/mm3 d. Sodium 134 mEq/L