A male client tells the nurse that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. Which is the priority nursing problem for admission to the psychiatric unit?

Compromised family coping.

Ineffective sexual patterns.

Impaired environmental interpretation.

Disturbed sensory perception.

Answer and Explanation

The Correct Answer is D

Choice A rationale:
Compromised family coping may be a concern, but it is not the most immediate priority given the client's symptoms of altered reality.

Choice B rationale:
Ineffective sexual patterns is not the primary concern in this scenario, as the client's delusional beliefs and hallucinations take precedence.

Choice C rationale:
Impaired environmental interpretation may be relevant, but it is not the most immediate priority compared to addressing the client's altered perception of reality.

Choice D rationale:
The client's delusional beliefs and hallucinatory experiences suggest disturbed sensory perception, which is a priority nursing problem that requires immediate attention and intervention. These symptoms may indicate a serious mental health condition, such as psychosis, that necessitates psychiatric evaluation and care.

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Correct Answer is B

Explanation

A. Assisting the client with relaxation techniques within the group may be ineffective for severe anxiety because the client may be too overwhelmed by the environment to participate or focus.

B. Escorting the client from the group to a quieter environment is the most effective intervention for severe anxiety. Reducing external stimuli allows the client to regain composure and prevents escalation of physiological and psychological stress responses.

C. Providing education about coping strategies is appropriate for mild or moderate anxiety, but during severe anxiety the client is unlikely to process or retain information effectively.

D. Asking the client to describe or identify the source of feelings can increase anxiety and is not therapeutic during a severe anxiety episode. Exploration of triggers is more appropriate once the client is calmer.

Correct Answer is B

Explanation

A. Helping the client practice relaxation techniques within the group may not be effective for severe anxiety because the environment may still be overstimulating. The client may not be able to focus or participate until anxiety decreases.

B. Escorting the client from the group to a quieter environment is the priority intervention for severe anxiety. Reducing environmental stimuli helps the client regain control, decreases physiological arousal, and allows the nurse to implement therapeutic interventions safely.

C. Providing education about coping strategies is appropriate for mild to moderate anxiety but is ineffective during a severe anxiety episode because the client’s ability to process information is impaired.

D. Asking the client to describe and identify the source of anxiety can increase stress and is not appropriate during a severe anxiety state. Therapeutic exploration is better initiated once the client’s anxiety is reduced.

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A male client tells the nurse that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. Which is the priority nursing problem for admission to the psychiatric unit?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse who is co-leading group therapy recognizes that a client is beginning to experience severe levels of anxiety. Which intervention is best for the nurse to implement?

Correct Answer is B

Explanation

A nurse who is co-leading group therapy recognizes that a client is beginning to experience severe levels of anxiety. Which intervention is best for the nurse to implement?

Correct Answer is B

Explanation

Patient Data Exhibits here The nurse is reviewing the physician's orders. Which of the following physician's orders requires priority attention from the nurse? Select all that apply.

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