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.Ask the client to identify the bomb in the room.
B.Initiate disaster protocols per facility policies and procedures.
C.Assess the client for evidence of a perceptual disturbance.
D.Convince the client that there is no bomb in their room.

Answer 1

The nurse should assess the client for evidence of a perceptual disturbance. This will help understand the client's state and address safety concerns.

Step-by-step explanation:

The nurse should take the action of assessing the client for evidence of a perceptual disturbance. This is because the client's report of a bomb being placed in their room could be a symptom of their schizophrenia. Schizophrenia often involves perceptual disturbances, such as hallucinations or delusions, that can cause the person to have false beliefs or experiences.

By assessing the client for evidence of a perceptual disturbance, the nurse can better understand the client's current state and address any immediate safety concerns. This assessment can also help determine the appropriate course of action or interventions to support the client's well-being.

Initiating disaster protocols or trying to convince the client that there is no bomb in their room would not address the underlying issue of the client's perceptual disturbance. It is important for the nurse to provide compassionate and evidence-based care by first assessing the client's mental status and addressing their specific needs.