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. Avoidance: Avoidance is a coping mechanism, not a symptom itself.
b. Obsessive-compulsive disorder (OCD): OCD involves intrusive thoughts and repetitive behaviours, not physical symptoms like limb weakness.
c. a conversion disorder: Conversion disorder is a psychological condition where emotional distress manifests as physical symptoms, like limb weakness, with no medical explanation.
d. A fracture: A fracture is a physical injury with a demonstrable cause, unlike the unexplained weakness in conversion disorder.

A. "We can keep the scatter (throw) rug in the bathroom for safety." B. "One family member should provide all care for the client when at home." C. "We should leave food by the bedside in case the client gets hungry." D. "We can use respite care for short term relief for caregiving."

Correct Answer is D

Explanation

a. "We can keep the scatter (throw) rug in the bathroom for safety." This is incorrect because scatter rugs are a fall hazard and should be removed.
b. "One family member should provide all care for the client when at home." This is incorrect because caregiving should ideally be a shared responsibility to prevent caregiver burnout.
c. "We should leave food by the bedside in case the client gets hungry." This is incorrect because it can pose choking hazards and does not address proper supervision for eating.
d. "We can use respite care for short term relief for caregiving." This is correct as it shows understanding of the importance of respite care to prevent caregiver burnout and ensure sustained quality care for the client.

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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?

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Naxlex Comprehensive Predictor Exams

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