A nurse is working with a client who is delusional. The client ...

[Bob-Dole]

A nurse is working with a client who is delusional. The client says to the nurse, The leaders of a religious cult are being sent to assassinate me. Which of the following is the best response by the nurse?
 
  1. I don't believe that what you are telling me is true.
  2. There are no religious cults in this area that are going to kill you.
  3. What makes you think that cult members are being sent to hurt you?
  4. I don't know about a religious cult. Are you afraid that people are trying to hurt you?

Question 2

The nurse is assisting in providing an educational session to new mothers regarding the methods that will decrease the risk of recurrent otitis media in infants.
 
  Which of the following statements, if made by a mother in the group, indicates a need for further instruction? 1. I need to feed the infant in an upright position.
  2. I should not provide the infant with a bottle during naptime.
  3. Bottle-feeding should be discontinued as soon as possible.
  4. I need to discontinue breast-feeding as soon as possible.

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Answer to Question 1

4

Rationale: The nurse who disagrees with a client's delusions may make the client more defensive and cling to the delusions even more firmly. It is most therapeutic for the nurse to empathize with the client's experience. The nurse can also use the opportunity to try to explore further the meaning of the experience for the client. I don't believe that what you are telling me is true. There are no religious cults in this area that are going to kill you. and What makes you think that cult members are being sent to hurt you? are nontherapeutic responses.

Answer to Question 2

4

Rationale: To decrease the risk of recurrent otitis media, mothers should be encouraged to breast-feed during infancy, discontinue bottle-feeding as soon as possible, feed the infant in an upright position, and never give the infant a bottle in bed. Additionally, parents should be told not to smoke in the child's presence because passive smoking increases the incidence of otitis media.

[Bob-Dole]

TY

[asdfasdf]

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