A psychiatric-mental health nurse is conducting an initial interview with a client admitted for hallucinations and abdominal pain. The client is focused on the pain and cannot concentrate on the assessment questions being asked. What is the initial desired outcome of the client?
client's anxiety level decreased
client's pain level decreased
assessment completed
client understood the importance of the assessment
The Correct Answer is B
A. client's anxiety level decreased: While reducing anxiety is important, it is not the initial priority when a client is experiencing physical pain that is affecting their ability to engage in the assessment.
B. client's pain level decreased: The initial desired outcome is to address the client's immediate physical pain. Once the pain is managed, the client will likely be better able to participate in the assessment and respond to questions about their mental health.
C. assessment completed: Completing the assessment is important, but it should not be prioritized over managing the client's immediate physical pain, which is currently hindering their ability to participate.
D. client understood the importance of the assessment: The client’s understanding of the assessment’s importance is less critical than addressing their immediate physical discomfort, which is a more pressing concern in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Place the client in a private room. This is the correct action because clients with radioactive implants need to be isolated to minimize radiation exposure to others.
B. Place a chair next to the bed to allow the spouse to sit. While emotional support is important, prolonged close contact with someone who has a radioactive implant is not recommended due to the risk of radiation exposure.
C. Have visitors wear dosimeters for safety. While this is a good safety measure, the primary concern is limiting visitors and ensuring the client is in a private room to minimize exposure.
D. Allow visitors to telephone only. While telephone communication can be safe and supportive, the best initial action is to place the client in a private room to control radiation exposure.
Correct Answer is C
Explanation
A. "I can see that you're uncomfortable now, so we can wait until tomorrow." Delaying the medication could worsen the client's condition and does not address the underlying reason for the refusal.
B. "If you refuse these pills, you'll have to get an injection." This response is coercive and could damage trust between the client and the nurse. It does not explore the client's concerns.
C. "What is it about the medicine that you don't like?" This response is therapeutic as it opens a dialogue with the client to understand their concerns, which can help in addressing the reluctance and promoting adherence to the medication.
D. "You know you have to take this medicine for your own good." This response is paternalistic and dismisses the client's autonomy and concerns, which may lead to further resistance.
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