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 D

Explanation

a. Clang association: Clang associations involve the use of words based on their sound rather than their meaning, often rhyming or having a similar sound. This pattern is not evident in the client’s response.
b. Word salad: Word salad refers to a jumble of words or phrases that lack logical coherence, which is not characteristic of the given response. The client's speech, while disorganized, still contains recognizable connections.
c. Ideas of reference: Ideas of reference involve the belief that common elements of the environment are directly related to oneself. This pattern is not shown in the client's response.
d. Loose association: Loose associations involve thoughts that are not logically connected to one another. The client’s response shows a series of loosely connected ideas, fitting the pattern of loose associations

A. "I know I can't use physical force anymore, but I can intimidate someone with my words." B. "Because my wife seems to be the one to set me off, I've decided never to see her again." C. "It's bad to feel as angry as I feel. I'm working on eliminating this evil feeling completely." D. "I realize I have a problem expressing my anger appropriately."

Correct Answer is D

Explanation

a. "I know I can't use physical force anymore, but I can intimidate someone with my words." This indicates that the client still considers using intimidation, which is not a healthy way of managing anger or aggression.
b. "Because my wife seems to be the one to set me off, I've decided never to see her again." Avoiding a trigger rather than managing the response to it does not indicate progress in anger and aggression management.
c. "It's bad to feel as angry as I feel. I'm working on eliminating this evil feeling completely." Viewing anger as entirely negative and trying to eliminate it rather than managing it constructively does not show effective anger management.
d. "I realize I have a problem expressing my anger appropriately." This is correct because recognizing and admitting the problem is a critical first step toward making meaningful changes in managing anger and aggression.

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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 D

Explanation

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Correct Answer is D

Explanation

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