A 28-year-old female client was admitted 3 days ago after she ran nude through the streets, shouting that she was the "Queen of Hearts." The client has remained delusional since admission. An initial expected outcome would be that the client wil
1. Allow the nurse to logically dispute the delusion
2. Distinguish external boundaries
3. Engage in reality-oriented conversation
4. Explain why she thinks she is the "Queen of Hearts"
ANS: 3
Delusions are not reality-oriented; thus an appropriate outcome would be that client will engage in reality-oriented conversation rather than discussing delusional beliefs. 1. Delusions are fixed, false beliefs. Clients rarely accept anyone using logic to dispute them. 2. Data are not present to suggest boundary disturbance. 4. Explaining the delusion is not progress; it suggests the client still holds to the belief.
You might also like to view...
When the nurse asks for a description of who lives with a child, the method of discipline, and the support system of the child, what part of the assessment is being performed?
a. Family history b. Review of systems c. Functional assessment d. Reason for seeking care
A 45-year-old woman with diabetes who has been hospitalized with diabetic ketoacidosis. Which of the following is most important for the nurse to assess during bath time?
a. Skin bruising b. Condition of teeth c. Sensation to the foot d. Skin folds for dirt
The nurse is preparing intravenous fluids for a patient whose serum sodium is 156 mmol/L. Which types of fluid would the nurse select?
1. 10% dextrose in water 2. Lactated Ringer's 3. 0.45% normal saline 4. 5% dextrose and 0.45% normal saline
A sterile field consists of which of the following? (Select all that apply.)
a. Sterile tray b. Work surface draped with a sterile towel c. Table covered by a large sterile drape d. Patient's bedside table