A client requests permission for the spouse to remain in the room during the admission assessment. While interviewing the client, the nurse notes a discrepancy between the client's verbal and nonverbal communication. Which action should the nurse take?

Ignore the nonverbal behavior and focus on the client's verbal messages.

Integrate the verbal and nonverbal messages and interpret them as one.

Ask the client's spouse to interpret the discrepancy.

Pay close attention and document the nonverbal messages.

Answer and Explanation

The Correct Answer is D

A.   Ignoring nonverbal behavior may overlook important cues that could provide valuable insight into the client's condition and needs.
B.   Integrating verbal and nonverbal messages is important, but it may not address the discrepancy or the potential significance of the nonverbal cues.
C.   Asking the client's spouse to interpret the discrepancy may not be appropriate or effective, as the spouse may not fully understand the client's nonverbal cues or their significance.
D.   Paying close attention and documenting nonverbal messages allows the nurse to gather comprehensive data and potentially explore the observed discrepancy further in subsequent interactions or assessments.

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Correct Answer is C

Explanation

A. Episodic intervals of pruritus (itching) may suggest a dermatological condition or irritation of the scalp, but they do not directly indicate that the hair loss is not disease-related.
B. Erythema (redness) of the localized lesions may suggest inflammation or irritation but does not necessarily indicate that the hair loss is not disease-related.

C. Ecchymotic blood accumulations (bruising) suggest trauma or repeated pulling at the hair, which is not typically associated with disease-related causes. This finding can indicate a behavioral issue, such as trichotillomania (a compulsive hair-pulling disorder), where physical damage to the scalp can result in bruising and bald patches. The presence of ecchymosis supports a mechanical, non-disease-related cause of hair loss.

D. Evidence of patches of lost hair alone does not confirm whether the hair loss is disease-related or non-disease-related. Patches of hair loss can occur with both behavioral conditions (e.g., trichotillomania) and diseases (e.g., alopecia areata, fungal infections).

A. "I understand that you're angry and unhappy. Let's explore ways in which you overreact." B. "I hear your frustration about losing control. Tell me how this affects your daily life." C. "Knowing the cause of your symptoms will make them easier to handle." D. "Do all that you can to learn all that you can while you are here. You can get better."

Correct Answer is B

Explanation

A. This comment may come across as invalidating the client's feelings by assuming overreaction, which could potentially escalate the situation.
B. This response acknowledges the client's feelings and invites further exploration, fostering a therapeutic relationship and understanding of the client's experiences.
C. While understanding the cause of symptoms is important, it may not necessarily make them easier to handle, and it could divert focus from addressing the client's immediate concerns.
D. While encouragement is positive, this comment does not directly address the client's feelings or concerns, which is essential for building a therapeutic relationship.

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A client requests permission for the spouse to remain in the room during the admission assessment. While interviewing the client, the nurse notes a discrepancy between the client's verbal and nonverbal communication. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A preschool-aged girl tells the school nurse that her hair hurts. The nurse finds that the child's hair has been arranged to cover several small bald spots. Which finding indicates to the nurse that the hair loss is not disease related?

Correct Answer is C

Explanation

A client is admitted to the mental health unit with a bipolar disorder. When seeking to establish a therapeutic relationship and interacting with the client, which comment is best for the nurse to make?

Correct Answer is B

Explanation

A client with depression does not want to communicate with friends, uses television watching as a means of escaping responsibilities, and describes the inability to handle personal circumstances. Which coping strategy should the nurse include in the plan of care?

The nurse is performing intake interviews at a psychiatric clinic. A client with a known history of drug abuse reports having had a heart attack four years ago. Use of which substance places the client at highest risk for myocardial infarction?

The nurse develops a plan of care for a female client who scratches her wrists in attempts to deal with anxiety. Which client outcome is most important to include in the plan of care?