During a client intake assessment, the nurse asks both physiological and psychosocial questions. The client angrily responds, "I'm here for my heart, not my head problems." What is the nurse's best response?

Why are you concerned about these types of questions?"

"We can skip these questions, if you like. It isn't imperative that we complete this section."

"It is just a routine part of our assessment. All clients are asked these same questions."

Psychological factors like excessive stress have been found to affect medical conditions"

Answer and Explanation

The Correct Answer is D

a. "Why are you concerned about these types of questions?"
This response can seem confrontational and might increase the client's defensiveness.
b. "We can skip these questions, if you like. It isn't imperative that we complete this section."
Skipping the questions can lead to an incomplete assessment, and it does not address the client's concern.
c. "It is just a routine part of our assessment. All clients are asked these same questions."
While this is true, it does not explain the importance of the questions and may seem dismissive.
d. "Psychological factors like excessive stress have been found to affect medical conditions."
This response explains the rationale behind the questions and how they relate to the client's overall health, potentially helping the client understand the importance of a holistic assessment.

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Correct Answer is A

Explanation

a. Recovery from anorexia nervosa is a marathon, not a sprint. Setting small, achievable goals like understanding the importance of nutrition is crucial for initial progress.
b. Aiming for immediate, perfect dietary adherence is unrealistic and can be discouraging. Building healthy eating habits takes time and support.
c. Unrealistic weight gain goals can be demotivating and potentially harmful. Weight gain should be gradual and monitored by a healthcare professional.
d. A sudden high-calorie diet can be overwhelming for someone with a restricted eating pattern and could lead to gastrointestinal distress.

A. Clinically significant distress in occupational functioning. B. Sudden unexpected travel or confused wandering. C. An inability to recall their parent's contact information. D. Occasional periods of forgetfulness

Correct Answer is B

Explanation

a. Clinically significant distress in occupational functioning. While distress in occupational functioning may occur, it is not specific to dissociative fugue and is more broadly associated with various mental health disorders.
b. Sudden unexpected travel or confused wandering. This choice is correct because dissociative fugue is characterized by sudden, unexpected travel away from one's home or usual place of work, with an inability to recall some or all of one's past.
c. An inability to recall their parent's contact information. While memory loss is part of dissociative fugue, the focus is on broader, more significant amnesia than just inability to recall specific information like contact details.
d. Occasional periods of forgetfulness. This does not capture the severity or the specific nature of the amnesia involved in dissociative fugue.

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During a client intake assessment, the nurse asks both physiological and psychosocial questions. The client angrily responds, "I'm here for my heart, not my head problems." What is the nurse's best response?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While planning care for a client with anorexia nervosa, the nurse determines that a realistic outcome would be that the client will:

Correct Answer is A

Explanation

The nurse is providing care for a client diagnosed with dissociative fugue. Which behaviors would the nurse expect to see with this client?

Correct Answer is B

Explanation

A client, who was diagnosed with Post Traumatic Stress Disorder (PTSD), is now experiencing flashbacks and is displaying irritable behavior. The nurse would:

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