章节:Schizophrenia, Other Psychoses, and Cognitive Disorders

SC
正确指数:100% 正确的次数:0 错误的次数:0 7361---A client reports having thoughts of being followed by foreign agents who are after his secret papers. Which response by the nurse is most appropriate when responding to the client’s disturbed thought process?

Saunders Comprehensive Review for the NCLEX-RN® Examination, 7e (Saunders Comprehensive Review for Nclex-Rn)

1. “I do not see any foreign agents.”
2. “I think these thoughts are frightening to you.”
3. “I do not know what you mean.”
4. “I would like you to come to group with me right now.”

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正确答案:
2. “I think these thoughts are frightening to you.”
解释 :
The client’s disturbed thought process likely reflects this client’s paranoid delusions. The nurse should acknowledge that the thoughts are frightening the client. Telling the client the nurse does not see any foreign agents is an appropriate nursing response if the client is having disturbed visual sensory perception and is having visual hallucinations. Telling the client the nurse does not understand what the client means is an appropriate response if the client has impaired verbal communication. Suggesting that a client participate in group activities would be appropriate if the client had a nursing diagnosis of social isolation and was staying in his room.