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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Related Questions
Correct Answer is C
Explanation
A. Traumatic flashbacks: Flashbacks are more commonly associated with post-traumatic stress disorder (PTSD), not dementia. Clients with dementia may experience confusion or memory loss but not typically flashbacks.
B. Clang associations: Clang associations, which involve the use of rhyming words or sounds that are not connected in meaning, are more common in conditions like schizophrenia, not dementia.
C. Difficulty finding words: Difficulty finding words (aphasia) is a common symptom of dementia. As the condition progresses, clients often experience challenges with communication, including word-finding difficulties and trouble with speech.
D. Revenge seeking behavior: Revenge-seeking behavior is not a typical characteristic of dementia. While individuals with dementia may become agitated or exhibit behavioral changes, these are usually related to confusion or frustration, not planned revenge.
Correct Answer is ["C","D","E","F","H","I"]
Explanation
Rationale for correct choices:
- Seizures: Seizures are a severe and life-threatening manifestation of alcohol withdrawal that require immediate intervention. They may lead to complications like injury or status epilepticus if not managed promptly.
- Increased blood pressure: Elevated blood pressure is a common sign of alcohol withdrawal and increases the risk of cardiovascular events such as stroke. Close monitoring and intervention are necessary to prevent complications.
- Increased heart rate: Tachycardia is commonly seen in alcohol withdrawal, increasing the risk of arrhythmias and cardiovascular stress. Management of heart rate is essential for maintaining stability.
- Diaphoresis: Diaphoresis, or excessive sweating, is part of the autonomic response during alcohol withdrawal and indicates significant distress in the body. It requires monitoring to ensure proper fluid and electrolyte balance.
- Vomiting: Vomiting in alcohol withdrawal can lead to dehydration and electrolyte imbalances, which can worsen the client’s condition. Immediate attention and interventions are needed to prevent further complications.
- Tremulousness: While often mild, tremors indicate CNS hyperexcitability and can escalate to more severe forms of withdrawal, including seizures or delirium tremens. It requires close monitoring and often pharmacological management to prevent progression.
Rationale for incorrect choices:
- Impaired cognition: Impaired cognition may occur due to alcohol intoxication or withdrawal but does not require immediate medical attention unless it is severe enough to affect the client’s ability to function or respond appropriately.
- Insomnia: Insomnia is common in alcohol withdrawal and can be distressing, but it is not life-threatening. It can be managed through appropriate therapeutic interventions but does not require urgent care.
- Lack of appetite: Loss of appetite is a common symptom of alcohol withdrawal and may be associated with gastrointestinal symptoms. It should be monitored but does not require immediate follow-up unless it leads to severe malnutrition.
- Malaise: Malaise is a general symptom of alcohol withdrawal and indicates a general sense of discomfort. It is important to monitor but does not require immediate intervention unless accompanied by more severe symptoms.
Complete the following sentence by using the lists of options.
The client is at risk of developing