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In performing a psychosocial assessment, the nurse begins by asking questions that encourage the client to describe problematic behaviors and situations. The next step is to elicit the client's:
- A. feelings about what has been described
- B. thoughts about what has been described
- C. possible solutions to the problem
- D. intent in sharing the description
Correct Answer: B
Rationale: Eliciting the client's thoughts after describing issues provides insight into their perspective and interpretation, guiding further assessment. Feelings and solutions come later.
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A nurse is teaching a group of clients with a diagnosis of Schizophrenia who are nearing discharge from a residential care facility. An essential topic to include is:
- A. pathophysiology of the disease and expected symptoms.
- B. how to recognize and manage symptoms of relapse.
- C. the need to take extra medication when feeling stressed.
- D. the importance of contact with follow-up care daily.
Correct Answer: B
Rationale: Clients are usually aware of the symptoms that indicate relapse is occurring. The client needs to know how to find a safe environment and to seek help. The first two stages of relapse are more difficult to recognize because they do not present symptoms that indicate psychosis. Initially, the client feels anxious and overwhelmed, and might become withdrawn. This is the crucial period to intervene. The client needs to go to a safe environment with someone who is trusted, avoid negative people, and decrease stimuli and stress.
A nurse notes that an elderly client suddenly does not keep appointments and is not wearing appropriate clothing. Which statement by the client raises the suspicion of financial abuse?
- A. I am having difficulty paying for this new antibiotic the physician prescribed.
- B. I am a little short on cash since my daughter moved in to help me.
- C. I have not felt like shopping since the weather has gotten worse.
- D. People do not realize how difficult it is to make ends meet on a fixed income.
Correct Answer: B
Rationale: Signs of financial abuse include an inability to pay for necessities like clothes, and the statement about being short on cash since the daughter moved in suggests possible misuse of funds by a caregiver.
The nurse suspects an elderly client has been the victim of abuse. The client denies abuse and declines assistance. The nurse's next action should be to:
- A. do nothing; the client has the right to refuse treatment.
- B. report the incident to the police.
- C. arrange an appointment with the client's next of kin.
- D. educate the client about available services.
Correct Answer: D
Rationale: Although clients do have the right to refuse treatment, the nurse should remain nonjudgmental and inform the client of available services. Frequently elders are not aware of existing programs.
A nurse observes a client sitting alone and talking. When asked, the client reports that he is 'talking to the voices.' The nurse's next action should be:
- A. touching the client to help him return to reality
- B. leaving the client alone until reality returns
- C. asking the client to describe what is happening
- D. telling the client there are no voices
Correct Answer: C
Rationale: Asking the client to describe the hallucinations validates their experience and provides insight into their condition, aiding therapeutic communication. Touching may be intrusive, leaving them alone is non-therapeutic, and denying the voices dismisses their reality.
A client receiving preoperative instructions asks questions repeatedly about when to stop eating the night before the procedure. The nurse tries to refocus the client. The nurse notes that the client is frequently startled by noises in the hall. Assessment reveals rapid speech, trembling hands, tachypnea, tachycardia, and elevated blood pressure. The client admits to feeling nervous and having trouble sleeping. Based on the assessment, the nurse documents that the client has:
- A. mild anxiety.
- B. moderate anxiety.
- C. severe anxiety.
- D. a panic attack.
Correct Answer: C
Rationale: In severe anxiety, a client focuses on small or scattered details. The person is unable to solve problems. With mild anxiety, stimuli are readily perceived and processed, and the ability to learn and solve problems is enhanced. Moderate anxiety narrows the perceptual field, but the client notices things brought to his attention. During a panic attack, the person is disorganized and might be hyperactive or unable to speak or act.