During a client intake assessment, the nurse asks both physiological and psychosocial questions. The client angrily responds, "I'm here for my heart, not my head problems." What is the nurse's best response?

Why are you concerned about these types of questions?"

"We can skip these questions, if you like. It isn't imperative that we complete this section."

"It is just a routine part of our assessment. All clients are asked these same questions."

Psychological factors like excessive stress have been found to affect medical conditions"

Answer and Explanation

The Correct Answer is D

a. "Why are you concerned about these types of questions?"
This response can seem confrontational and might increase the client's defensiveness.
b. "We can skip these questions, if you like. It isn't imperative that we complete this section."
Skipping the questions can lead to an incomplete assessment, and it does not address the client's concern.
c. "It is just a routine part of our assessment. All clients are asked these same questions."
While this is true, it does not explain the importance of the questions and may seem dismissive.
d. "Psychological factors like excessive stress have been found to affect medical conditions."
This response explains the rationale behind the questions and how they relate to the client's overall health, potentially helping the client understand the importance of a holistic assessment.

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Correct Answer is C

Explanation

a. "I can make that promise to you based on nurse-client privilege." Nurse-client confidentiality is important, but it doesn't apply to threats of violence. The nurse has a duty to protect the client and others.
b. "Those kinds of thoughts will make your hospitalization longer." While true, this response doesn't directly address the safety concern and might be perceived as judgmental.
c. "I cannot promise that. Confidentiality does not include plans to hurt others." This is a clear and honest statement. It explains the limitations of confidentiality and prioritizes safety.
d. "You should share this thought with your psychiatrist." While encouraging the client to talk to a psychiatrist is a good suggestion, it doesn't directly address the confidentiality issue or the immediate threat.

A. "I am less likely to get an infection while taking this medication." B. "Weight loss is a sign that my medication dose is too low." C. "I will contact my healthcare provider if I have difficulty urinating." D. "I will stop taking this medication once my hallucinations go away."

Correct Answer is C

Explanation

a. "I am less likely to get an infection while taking this medication." This statement is incorrect. Chlorpromazine can actually increase the risk of infection due to potential side effects like agranulocytosis (a drop in white blood cell count).
b. "Weight loss is a sign that my medication dose is too low." This statement is incorrect. Chlorpromazine typically causes weight gain rather than weight loss.
c. "I will contact my healthcare provider if I have difficulty urinating." This statement indicates an understanding of one of the potential side effects of chlorpromazine, which can cause urinary retention due to its anticholinergic properties.
d. "I will stop taking this medication once my hallucinations go away." This statement is incorrect. Discontinuing antipsychotic medication without a healthcare provider's guidance can lead to a relapse of symptoms.

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During a client intake assessment, the nurse asks both physiological and psychosocial questions. The client angrily responds, "I'm here for my heart, not my head problems." What is the nurse's best response?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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