Author Question: A patient tells the nurse, Air Force jets flying overhead are looking for me. They want to capture ... (Read 70 times)

Cooldude101 · **on:** Jul 19, 2018

A patient tells the nurse, Air Force jets flying overhead are looking for me. They want to capture me. The patient has not previously verbalized this information. The nurse's initial interventions should

a. set firm limits on disruptive behaviors.
b. forcefully refute all perceptual distortions.
c. encourage complete description of delusions.
d. voice doubt about delusions without arguing.

Question 2

A newly admitted patient is mute, immobile, and holds a fixed body position for long periods. The nurse caring for this patient should

a. assign unlicensed assistance personnel to feed the patient.
b. provide a stimulating, active environment.
c. encourage independent social behaviors.
d. forewarn the patient before touching.

aliotak · **Reply #1 on:** Jul 19, 2018

Answer to Question 1

D
A nurse cannot agree with a delusion, but arguing is counterproductive, because it might cause the patient to cling to the idea. Voicing doubt and stating one's own perception of reality is therapeutic. Encouraging discussion of the delusion reinforces it. Because the behavior described is not disruptive, this principle is not relevant.

Answer to Question 2

D
Nurses should explain the need for and purpose of touch to patients before actually touching. This is particularly true for patients who are at highest risk for misinterpreting touch: those who are inattentive to reality or those who are suspicious. The environment should be calm and predictable. A patient who is mute and motionless is incapable of independent social behaviors. The patient's oral intake should be monitored, but the correct response also applies to feeding, if it is necessary.