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    Ati lpn mental health proctored exam

    A nurse is caring for a client who has a history of alcohol use disorder and has been hospitalized for alcohol intoxication. The nurse enters the room and finds the client shouting "Get those bugs off of me." Which of the following responses should the nurse make?

    Explanation & Rationale

    A. "I'm sure that the bugs you see will not harm you.": This response validates the hallucination and may increase the client's anxiety. B. "I don't see any bugs, but you seem very frightened.": This response maintains reality orientation while acknowledging the client’s emotional state, a therapeutic and non-confrontational approach. C. "Let's get out of your room so that the bugs will not bother you": This reinforces the hallucination and may worsen disorientation. D. “There are no bugs in here. This is part of your illness.": This is too blunt and dismissive, potentially increasing defensiveness or agitation.

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