A home health nurse drives up to the house of her client, who has schizophrenia with manic episodes. The client is sitting on his front porch with a shotgun in his arms. Which of the following actions should the nurse take?
Honk the car horn to get the client’s attention.
Stop the car in the client’s driveway and call the authorities.
Keep driving in a path that is going away from the client’s house.
Calmly speak the client’s name out of the car window.
The Correct Answer is C
Choice A reason:
Honking the car horn to get the client’s attention could startle the client and potentially escalate the situation. It is important to avoid actions that could provoke a violent response or increase the client’s agitation. Safety is the primary concern, and honking the horn does not ensure the nurse’s or the client’s safety.
Choice B reason:
Stopping the car in the client’s driveway and calling the authorities is not the safest immediate action. While calling the authorities is necessary, stopping in the driveway could put the nurse in a vulnerable position. It is safer to move away from the immediate vicinity before making the call.
Choice C reason:
Keeping driving in a path that is going away from the client’s house is the safest immediate action. This ensures the nurse’s safety by creating distance from the potentially dangerous situation. Once at a safe distance, the nurse can then call the authorities to handle the situation appropriately.
Choice D reason:
Calmly speaking the client’s name out of the car window could also escalate the situation. The client may perceive this as a threat or intrusion, leading to unpredictable behavior. It is safer to avoid direct interaction and ensure personal safety first.
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Correct Answer is C
Explanation
Choice A reason:
Delusions of grandeur are a type of delusion where an individual believes they have exceptional abilities, wealth, or fame. This is not the correct answer because the client’s reaction of thinking others are making fun of them does not align with the belief of having grandiose qualities. Delusions of grandeur typically involve an inflated sense of self-importance, which is not evident in the scenario described.
Choice B reason:
Loose association refers to a thought disorder where ideas are presented with little or no logical connection. This is not the correct answer because the client’s reaction is more about misinterpreting the actions of others rather than displaying disorganized thinking. Loose associations would manifest as speech that is difficult to follow due to the lack of coherent connections between thoughts.
Choice C reason:
Ideas of reference involve the belief that insignificant remarks, events, or objects in one’s environment have personal meaning or significance. This is the correct answer because the client believes that the group’s laughter is directed at them, interpreting it as a personal attack. This misinterpretation of external events is a hallmark of ideas of reference, which is a common symptom in schizophrenia.
Choice D reason:
Magical thinking involves believing that one’s thoughts, words, or actions can cause or prevent specific outcomes in a way that defies the laws of cause and effect. This is not the correct answer because the client’s reaction does not involve any belief in their own ability to influence events through supernatural means. Instead, the reaction is based on a misinterpretation of the group’s behavior.
Correct Answer is C
Explanation
Choice A reason:
Honking the car horn to get the client’s attention could startle the client and potentially escalate the situation. It is important to avoid actions that could provoke a violent response or increase the client’s agitation. Safety is the primary concern, and honking the horn does not ensure the nurse’s or the client’s safety.
Choice B reason:
Stopping the car in the client’s driveway and calling the authorities is not the safest immediate action. While calling the authorities is necessary, stopping in the driveway could put the nurse in a vulnerable position. It is safer to move away from the immediate vicinity before making the call.
Choice C reason:
Keeping driving in a path that is going away from the client’s house is the safest immediate action. This ensures the nurse’s safety by creating distance from the potentially dangerous situation. Once at a safe distance, the nurse can then call the authorities to handle the situation appropriately.
Choice D reason:
Calmly speaking the client’s name out of the car window could also escalate the situation. The client may perceive this as a threat or intrusion, leading to unpredictable behavior. It is safer to avoid direct interaction and ensure personal safety first.