A nurse is caring for a client who has factitious disorder. The client states, "I am so tired of living like this. Maybe I should just end it all." Which of the following actions should the nurse take?
Assess the client for suicidal ideation and thoughts of self-harm.
Determine if the client has entered one of their alter personalities.
Encourage the client to use relaxation techniques.
Encourage the client to participate in group therapy sessions.
The Correct Answer is A
A. Assess the client for suicidal ideation and thoughts of self-harm. The client's statement about feeling tired of living and contemplating ending it all indicates a potential risk for suicide. It is essential for the nurse to conduct a thorough assessment of the client’s mental state, including any suicidal thoughts or plans, to ensure their safety.
B. Determine if the client has entered one of their alter personalities. This action is not relevant to factitious disorder, as it involves intentionally producing or feigning symptoms rather than dissociative identity disorder, which features the presence of distinct personality states.
C. Encourage the client to use relaxation techniques. While relaxation techniques can be beneficial for managing stress, they do not address the immediate risk of suicidal ideation and should not be prioritized over a safety assessment.
D. Encourage the client to participate in group therapy sessions. While group therapy can be beneficial, it may not be appropriate to encourage participation until the client's safety is ensured. Assessing for suicidal thoughts takes precedence to address any immediate risk to the client.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Shuffling walk. A shuffling walk is typically associated with parkinsonism or other movement disorders, which may occur with antipsychotic medications, but the specific symptom of restlessness more directly relates to other conditions.
B. Suicidal ideation. While monitoring for suicidal ideation is important in any client with psychosis, it is not specifically associated with the restlessness that the client reports in relation to chlorpromazine use.
C. Abnormal movements of the tongue and face. Abnormal movements of the tongue and face are more characteristic of tardive dyskinesia, which develops over a longer period of treatment. The acute restlessness the client is experiencing is more closely aligned with akathisia, a side effect of antipsychotic medications.
D. Oculogyric crisis. This condition involves involuntary upward eye movement and can occur as an acute dystonic reaction to antipsychotic medications like chlorpromazine. Given the client's report of restlessness, the nurse should monitor for this adverse effect, as it is more likely to manifest in the context of acute medication side effects.
Correct Answer is D
Explanation
A. Neglect. Neglect involves failing to provide essential care, such as food, medication, or hygiene, leading to harm or risk of harm. In this case, the issue is financial exploitation rather than neglect.
B. Emotional. Emotional abuse includes verbal threats, humiliation, intimidation, or psychological manipulation. While financial exploitation can cause emotional distress, the primary concern in this scenario is unauthorized financial activity.
C. Physical. Physical abuse involves the infliction of bodily harm, such as hitting, pushing, or restraining. There is no indication that the client has suffered physical injury or assault.
D. Economic. Economic (or financial) abuse occurs when a caregiver misuses or exploits an older adult’s financial resources without consent. Writing checks in the client’s name without permission is a clear example of financial exploitation.
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