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 D
Explanation
Choice A reason: Encouraging the client to internalize their feelings related to the loss is not advisable. Grief is a personal experience, and expressing emotions is a healthy part of the grieving process. Internalizing feelings can lead to unresolved grief and potential mental health issues.
Choice B reason: Changing the subject when the client expresses anger about their situation is not supportive. Anger is a natural stage of the grieving process, and it's important for the nurse to acknowledge the client's feelings and provide a safe space for them to express their emotions.
Choice C reason: Allowing the client to be alone during times of spiritual inadequacy may not be beneficial. While respecting the client's need for solitude is important, it's also crucial to offer support and presence, as isolation can exacerbate feelings of loneliness and despair.
Choice D reason: Offering to contact the client's spiritual advisor is a supportive action that can help meet the client's spiritual needs. Spiritual care is an integral part of holistic nursing care, and connecting the client with their spiritual support system can provide comfort and aid in the grieving process.
Correct Answer is B
Explanation
Choice A reason: Assisting the client to use new coping strategies is an important part of managing bipolar disorder, but it is not the first action a nurse should take when establishing a nurse-client relationship. Coping strategies will be more effective once a trusting relationship has been established and the client feels secure in sharing personal information.
Choice B reason: Establishing confidentiality guidelines with the client is the first and most crucial step in forming a therapeutic nurse-client relationship. It sets the foundation for trust and openness, ensuring the client understands that their personal information will be protected and shared only with those directly involved in their care.
Choice C reason: Helping the client to make behavioral changes is a goal in the treatment of bipolar disorder. However, before any interventions can be planned or implemented, the nurse must first establish a rapport and trust with the client, which begins with ensuring confidentiality.
Choice D reason: Sharing information with the client about their disorder is essential for their understanding and participation in care. However, this should occur after establishing a relationship in which the client feels comfortable and secure, knowing their privacy is respected.
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