A nurse is receiving a change-of-shift report about a group of assigned clients at a mental health facility. Which of the following clients should the nurse assess for risks related to sensory impairments?
A client who has conversion disorder
A client who has mild anxiety disorder
A client who has narcissistic personality disorder
A client who has severe obsessive-compulsive disorder
The Correct Answer is A
Choice A reason: This client experiences psychological stress that manifests as neurological symptoms, such as blindness, deafness, or paralysis, without an underlying medical cause. These deficits are real to the client, creating significant safety risks. The nurse must prioritize assessing their ability to navigate the environment safely to prevent falls or injuries related to these sudden sensory losses.
Choice B reason: Mild anxiety disorder typically does not involve sensory impairments. Anxiety may cause heightened awareness or sensitivity to stimuli but does not result in a loss of sensory function.
Choice C reason: Narcissistic personality disorder is characterized by patterns of grandiosity, need for admiration, and lack of empathy. It does not include sensory impairments as a symptom.
Choice D reason: While this client may engage in time-consuming rituals or repetitive behaviors that interfere with daily life, the disorder does not typically present with neurological or sensory impairments. Potential physical risks for these clients usually involve skin integrity issues from excessive washing or nutritional imbalances rather than the loss of primary senses like sight or hearing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: A blood glucose level of 256 mg/dL is significantly higher than the normal range and could indicate hyperglycemia, which is a serious side effect of risperidone. The provider should be notified immediately to manage this potential complication.
Choice B reason: A WBC count of 6,000/mm³ is within the normal range and does not typically warrant concern or the need to notify the provider.
Choice C reason: A platelet count of 250,000/mm³ is also within the normal range and is not indicative of an adverse reaction to risperidone.
Choice D reason: A sodium level of 140 mEq/L falls within the normal range and is not a cause for alarm in the context of risperidone therapy.
Correct Answer is B
Explanation
Choice A reason: This statement reflects a neutral observation of the client's behavior in therapy and does not indicate countertransference. Sharing feelings during group therapy sessions is a common and expected part of the therapeutic process, and the staff nurse's comment does not reveal any personal emotional response or projection onto the client.
Choice B reason: This statement is a clear example of countertransference. The staff nurse is identifying the client with a personal family member, which can cloud professional judgment. Such an emotional entanglement may lead to biased care, as the nurse may treat the client based on personal experiences with their brother rather than the client's individual needs and circumstances.
Choice C reason: Declining a client's inappropriate request for a date is a professional boundary that must be maintained. This statement does not reflect countertransference but rather appropriate professional conduct. It is important for the charge nurse to recognize that maintaining boundaries is crucial in a therapeutic setting, especially in cases of substance use disorder where clients may exhibit boundary-testing behaviors.
Choice D reason: This statement could be seen as a professional opinion regarding the client's need for accountability in their recovery process. It does not necessarily indicate countertransference unless the staff nurse's insistence on responsibility is driven by personal feelings or unresolved issues related to substance use.
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