Question

During morning rounds, a nurse finds a patient who has schizophrenia trembling and tearful in their bed. The patient 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?

1) Assess the client for signs of anxiety or distress
2) Immediately evacuate the client and inform the security staff
3) Call the client's family member to verify the claim
4) Ignore the client's statement as it may be due to the schizophrenia

Answer 1

The nurse should assess the client's emotional state, evacuate the client and inform security, and investigate the patient's claim without disregarding it.

Step-by-step explanation:

The nurse in this situation should take the following action:

1. Assess the client for signs of anxiety or distress: The nurse should first evaluate the patient's emotional state to determine the level of distress and anxiety in order to provide appropriate care.
2. Immediately evacuate the client and inform the security staff: Given the seriousness of the situation, it is crucial to ensure the safety of both the patient and the healthcare team. Evacuation and notifying security would be the appropriate response.
3. Do not ignore the client's statement: It is important not to dismiss the patient's claims solely based on their diagnosis of schizophrenia. While it is possible that the patient's delusions are contributing to the perceived threat, it is essential to investigate and assess the situation.