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. Pulling out their hair (Correct): Trichotillomania is a mental health disorder characterized by the repetitive pulling out of one's hair. This behavior often serves as a way to cope with anxiety or negative emotions. It's the defining characteristic of the condition.
b. Pretending to be sick: Malingering, or pretending to be sick for secondary gain, is not a characteristic behavior of Trichotillomania.
c. Aphanie: Aphanie is a complete or partial loss of the sense of touch. It's not related to anxiety relief or Trichotillomania.
d. Amnesia: Amnesia is memory loss. While anxiety can be a contributing factor in some amnestic cases, it's not a behavior used to relieve anxiety.

A. "Where do you buy your food?" B. "Does someone else prepare your meals?" C. "Tell me what you eat in a typical day. D. Are you taking any medications that change your taste of foods?"

Correct Answer is C

Explanation

a. "Where do you buy your food?" While this provides information about food access, it doesn’t directly assess nutritional intake.
b. "Does someone else prepare your meals?" This might provide insight into the client's independence, but it doesn't directly assess nutritional intake.
c. "Tell me what you eat in a typical day." This directly assesses the client’s dietary intake and provides a comprehensive view of their nutrition status.
d. "Are you taking any medications that change your taste of foods?" This is relevant but more specific to one aspect of dietary intake. It does not provide a full picture of the client’s nutritional status like option c.

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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

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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