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 D
Explanation
A. Sit with the client for a few minutes. While providing comfort is important, it does not address the immediate need to evaluate and manage a potentially serious condition.
B. Administer an analgesic. Administering analgesics without assessing the cause of the headache might mask symptoms of a serious issue. This is not the priority action.
C. Inform the nurse manager. Informing the nurse manager is important but does not directly address the client’s immediate needs or potential emergency.
D. Call the health care provider immediately. Reporting severe headache in a client with a cerebral aneurysm is critical as it could indicate worsening of the condition, such as aneurysm rupture or increased intracranial pressure. Immediate action is required to prevent further complications.
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.
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