A nurse is receiving change-of-shift report about a group of assigned clients at a mental health facility. Which of the following clients should the nurse assess for risks related to sensory impairments?
A client who has narcissistic personality disorder
A client who has mild anxiety disorder
A client who has severe obsessive-compulsive disorder
A client who has conversion disorder
The Correct Answer is D
Choice A reason: Narcissistic personality disorder involves grandiosity and interpersonal issues, not sensory impairments. There’s no direct link to vision, hearing, or motor deficits unless secondary conditions exist. Assessment priority would focus on behavior, not sensory risks, making this client less likely for this concern at shift start.
Choice B reason: Mild anxiety disorder causes worry or restlessness, but sensory impairments aren’t typical features. Physical symptoms like palpitations don’t equate to sensory loss. Other clients with neurological risks take precedence, so this client’s mild condition doesn’t warrant immediate sensory assessment.
Choice C reason: Severe OCD involves intrusive thoughts and rituals, potentially distracting from sensory input, but not impairing it directly. Sensory issues aren’t a hallmark, and assessment would target compulsions. This client’s risks are behavioral, not sensory, lowering their priority here.
Choice D reason: Conversion disorder presents with neurological symptoms like blindness or paralysis without organic cause, mimicking sensory impairments. Assessing this client first ensures safety, as these deficits could be active, posing immediate risks like falls. This aligns with the focus on sensory concerns, making it the priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Feeling the need to cut alcohol use (CAGE question) flags potential abuse, a strong self-harm risk factor via impulsivity or depression. In mental health screening, this directly ties to behaviors linked to suicide or injury, making it the most relevant question here.
Choice B reason: Liver damage indicates past alcohol effects but not current intent or emotional state tied to self-harm. It’s a physical outcome, not a behavioral risk marker. This question misses the psychological focus needed for screening, so it’s not the best choice.
Choice C reason: Twin birth relates to genetics or early stressors, but no direct evidence links it to self-harm risk universally. It’s too vague for mental health screening without context. This question lacks specificity to harm, making it irrelevant here.
Choice D reason: Family alcohol use suggests environmental risk but not the client’s own behavior or feelings, key to self-harm assessment. It’s indirect, missing personal intent or distress. This historical focus is less urgent than current indicators, so it’s incorrect.
Correct Answer is D
Explanation
Choice A reason: Speaking loudly escalates tension in an agitated client, mimicking confrontation and potentially worsening yelling or pacing. De-escalation requires a calm, low tone to soothe, not provoke. This action contradicts mental health principles for managing agitation, increasing risk, so it’s not appropriate here.
Choice B reason: Standing directly in front risks invading personal space, heightening agitation in a yelling, pacing client, possibly triggering aggression. A side approach maintains safety and openness, per de-escalation guidelines. This position endangers the nurse and client, making it an incorrect choice.
Choice C reason: Requesting restraints assumes immediate danger without de-escalation attempts, violating least restrictive care. Yelling and pacing alone don’t justify physical control unless harm is imminent. This premature escalation skips verbal intervention, so it’s not suitable unless safety fails.
Choice D reason: Short, simple sentences calm the client by reducing cognitive overload during agitation, facilitating understanding amid yelling and pacing. This de-escalation technique, part of crisis management, promotes cooperation safely. It’s a primary, effective step, making it a correct action here.
Choice E reason: Identifying stressors uncovers agitation triggers (e.g., fear, pain), guiding tailored de-escalation for a yelling, pacing client. This insight informs interventions, reducing escalation risk in mental health settings. It’s a proactive, therapeutic step, correctly included in the nurse’s response.
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