Nokea
The charge nurse of the psychiatric unit observes clients in the day area. Which client is exhibiting symptoms of a conversion disorder?
- A. A middle-aged man who is complaining of shortness of breath and is diaphoretic
- B. A young woman who suddenly goes blind with no indication of organic pathology
- C. An older adult who continuously complains of a headache and back pain
- D. An adolescent who becomes extremely anxious about going outside
Correct Answer: B
Rationale: Sudden blindness with no organic pathology suggests a functional neurological symptom disorder, which falls under conversion disorder. Shortness of breath and diaphoresis may indicate a medical condition or panic attack. Headaches and back pain could have various causes. Anxiety about going outside suggests agoraphobia or another anxiety disorder.
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A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The nurse also determine the client is homeless and is exhibiting suspiciousness. This client's plan of care should include what priority problem?
- A. Ineffective community coping
- B. Disturbed sensory perception
- C. Self-care deficit
- D. Acute confusion
Correct Answer: D
Rationale: Acute confusion is the priority problem because the client is disoriented, disorganized, and confused, indicating a cognitive impairment that needs immediate attention. Ineffective community coping may be a concern for a homeless individual but is not the priority in this scenario. Disturbed sensory perception typically involves alterations in visual, auditory, tactile, or olfactory senses, which may not be the primary issue. While self-care deficit could be a concern, it is not the priority when the client is disoriented.
A client with depression does not want to communicate with friends, uses television watching as a means of escaping responsibilities, and describes the inability to handle personal circumstances. Which coping strategy should the nurse include in the plan of care?
- A. Concentrate on and ventilate emotions when distressed
- B. Relax and reduce the amount of effort to solve the problem
- C. Shift attention from self to the needs and requests of others
- D. Focus on small achievable tasks, not taxing problems
Correct Answer: D
Rationale: Focusing on small achievable tasks promotes a sense of accomplishment, counteracting helplessness and supporting behavioral activation for depression. Ventilating emotions may not address avoidance. Reducing effort may worsen helplessness. Shifting attention to others does not directly address depressive symptoms.
The nurse observes a client with a history of psychosis repeatedly looking to the side and mumbling responses to no one present in that direction. Which comment is best for the nurse to make?
- A. You appear to be speaking with someone
- B. Let's talk about the next time this happens
- C. You need to be calm and focus on something else
- D. The voices you are hearing are not real
Correct Answer: A
Rationale: This comment acknowledges the client's behavior without judgment, validating their experience and encouraging further discussion. Focusing on the future, redirecting, or denying the voices may not be therapeutic and could invalidate the client's reality.
A young female client is admitted to the emergency room because she was raped that evening by her date. Which computer documentation should the nurse enter in the electronic medical record as the client's chief complaint?
- A. Client claims that she was forced to participate in sexual intercourse
- B. Client reported that she had sexual relations against her will
- C. Client has been sexually assaulted
- D. Client states, 'My date raped me tonight'
Correct Answer: D
Rationale: Client states, 'My date raped me tonight' is the most accurate and objective, using the client's own words to document the chief complaint without implying doubt ('claims') or minimizing the trauma. 'Sexual assault' is accurate but less specific.
The nurse continues to care for the patient
The client is a 19-year-old male who is in the emergency room for a leg injury. He states he was returning to his dorm from a party and fell about 5 feet (1.5 meters) into a small ravine on campus. The client states that he drinks socially and takes no medications for any health condition.
The nurse is listening to the client.
Because the client is a male, he is especially at risk for which psychosocial two sequalae of sexual assault?
- A. Suicide
- B. Depression
- C. Post-traumatic stress disorder
- D. Becoming an abuser
- E. Human immunodeficiency virus
- F. Chlamydia
Correct Answer: B,C
Rationale: B: Depression is common post-sexual assault due to psychological trauma. C: PTSD is frequent, with symptoms like flashbacks and anxiety. A: Suicide is a risk but not male-specific. D: Becoming an abuser is less common. E, F: HIV and chlamydia are physical, not psychosocial, risks.