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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Suppression is a conscious decision to delay paying attention to an emotion or need in order to cope with the present reality. It's unlikely that the client is consciously choosing to ignore the cause of their blackouts.
Choice B reason: Sublimation is a way of dealing with unacceptable impulses by unconsciously substituting acceptable forms of expression. This defense mechanism doesn't typically apply to explaining symptoms like blackouts.
Choice C reason: Projection involves attributing one's own unacceptable thoughts or feelings to another person. Since the client is providing an explanation for their own symptoms, rather than attributing them to someone else, projection is not the defense mechanism at play here.
Choice D reason: Rationalization involves justifying behaviors or feelings with logical reasons, even if they are not appropriate. The client's attribution of blackouts to low blood sugar, despite a diagnosis that suggests a psychological cause, is a form of rationalization.
Correct Answer is A
Explanation
Choice A reason: Asking the client about their hallucinations can provide valuable information about the content and nature of the hallucinations. This can help the nurse assess the client's current mental state and the potential impact of the hallucinations on their behavior and safety.
Choice B reason: Focusing the client on reality-based topics is a strategy that can be used after understanding the client's hallucinations. It's important to first acknowledge the client's experience before attempting to redirect their attention.
Choice C reason: Taking the client for a walk may be a good distraction technique, but it should not be the first action. The nurse needs to assess the client's safety and the potential risks associated with the hallucinations before engaging in activities.
Choice D reason: Encouraging the client to listen to music can be a therapeutic intervention to help distract from hallucinations. However, it is not the first action to take. The nurse should first understand the client's experience and ensure their safety.
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