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"
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
a. "Focus on the feelings generated by the hallucinations and present reality." This approach validates the child's experience and feelings while gently orienting them to reality, which is a therapeutic communication technique.
b. "Ignore what they are saying, while attempting to discover the underlying cause." Ignoring the child’s statements can make them feel dismissed and could increase their distress. It is important to address their experience directly and compassionately.
c. "Present objective evidence that the voices are not real." Presenting objective evidence may not be effective as the child’s belief in the voices can be very strong, and this approach may lead to further agitation.
d. "Tell them to stop discussing the voices." This approach is dismissive and does not help the child manage their symptoms or feel understood. It is important to engage with the child’s experience constructively.
Correct Answer is B
Explanation
a. Diphenhydramine: Diphenhydramine is an antihistamine that can also be used for its sedative properties to help calm an agitated client.
b. Ondansetron: Ondansetron is an antiemetic used to prevent nausea and vomiting, not for managing agitation or assaultive behavior. The nurse should question this order as it is not appropriate for the client's current symptoms.
c. Lorazepam: Lorazepam is a benzodiazepine used for its anxiolytic and sedative effects, making it appropriate for calming an agitated client.
d. Haloperidol: Haloperidol is an antipsychotic medication commonly used to manage severe agitation and aggressive behavior.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.