Question

During morning rounds, a nurse finds a client who has schizophrenia trembling and tearful in their bed. The client reports that a bomb was placed in their room by a family member during visiting hours. Which of the following actions should the nurse take?

A) Remove the client from the room immediately and search for the alleged bomb.
B) Tell the client that there's no bomb and it's just their imagination.
C) Notify the security staff to conduct a room search while staying with the client.
D) Call the family member to clarify the situation.

Answer 1

The nurse should notify the security staff to conduct a room search while staying with the client.

Step-by-step explanation:

The nurse should take action C) Notify the security staff to conduct a room search while staying with the client. It is important for the nurse to take the client's concerns seriously and ensure their safety. However, removing the client from the room and searching for the alleged bomb may escalate the client's anxiety and reinforce their delusions. Telling the client that there's no bomb may invalidate their experience and cause further distress.