A nurse in an outpatient mental health clinic is assessing a new client. Which of the following findings should the nurse immediately report to the provider?
The client is experiencing anisognosia
The client is experiencing command hallucinations
The client is exhibiting concrete thinking
The client is exhibiting a blunted affect
The Correct Answer is B
A. The client is experiencing anisognosia: Anisognosia, a lack of awareness of one's own illness, is common in various psychiatric disorders, particularly in psychotic disorders like schizophrenia. While it is concerning, it does not typically require immediate reporting.
B. The client is experiencing command hallucinations: Command hallucinations, where the client hears voices telling them to take harmful actions, pose a direct safety risk. These should be immediately reported to the provider for further evaluation and intervention.
C. The client is exhibiting concrete thinking: Concrete thinking is common in individuals with certain psychiatric conditions, such as schizophrenia or intellectual disabilities. While it limits abstract thought, it is not an immediate cause for alarm.
D. The client is exhibiting a blunted affect: A blunted affect, or reduced emotional expression, is a common symptom in various mental health disorders. It is important for diagnosis and treatment planning but is not an immediate emergency or urgent situation.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"D"}
Explanation
Rationale for correct choices:
- Mood: The client demonstrated a sad mood on Day 1, expressing feelings of hopelessness and suicidal ideation. While the mood lightened by Day 5, continued assessment is necessary to monitor for any further mood changes or shifts, particularly given the prior suicidal ideation.
- Energy level: The client is now requesting to jog and asking for financial planning recommendations, which could suggest increased energy or impulsivity. This shift in energy level after a depressive episode should be carefully assessed to ensure it is not indicative of a manic episode or potential risk for unsafe behavior.
Rationale for incorrect choices:
- Cognitive orientation: The client has been alert and oriented x 4 throughout the assessment, with no signs of cognitive impairment. Therefore, there is no immediate concern regarding cognitive orientation that requires follow-up.
- Family history: Although the family history of anxiety disorder is relevant for understanding the client’s background, it does not require immediate follow-up in this scenario. The priority is addressing the client's current emotional and energy-related changes.
- Substance use history: While the client has a history of opioid and cannabis use, this is important for overall treatment planning and future care. However, the immediate concern is the client's current emotional state and potential changes in mood or energy, rather than a substance use history that has already been considered in the client’s care plan.
Correct Answer is D
Explanation
A. The client does not recognize their partner: While this is concerning, it is a common symptom of Alzheimer's disease as it progresses. However, it is not immediately life-threatening or a direct risk to the client’s safety.
B. The client places their shoes on the wrong feet: This is a typical manifestation of cognitive decline in Alzheimer's disease. While it may affect the client's independence, it is not an urgent issue that requires immediate intervention compared to other symptoms.
C. The client is unable to remember their personal history: Memory loss, especially related to personal history, is a hallmark symptom of Alzheimer's disease. Although it affects the client's cognitive function, it is not a crisis situation requiring priority intervention.
D. The client engages in wandering: Wandering is the priority concern in this scenario. It poses a significant safety risk, as the client may become lost, confused, or injured. Ensuring the client's safety by addressing wandering behavior is essential in managing Alzheimer's disease.
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