What is the purpose of a nurse gathering client information?

enables the nurse to assign the appropriate Axis i diagnosis

enables the nurse to prescribe the appropriate medications

enables the nurse to mortify behaviors related to personality disorders

enables the nurse to make sound clinical judgments and plan appropriate care

Answer and Explanation

The Correct Answer is D

A. Enables the nurse to assign the appropriate Axis I diagnosis: Nurses typically do not assign Axis I diagnoses. Diagnosing mental health conditions is typically the responsibility of psychiatrists, psychologists, or other licensed mental health professionals. Nurses, however, play a crucial role in gathering information to contribute to the overall assessment process.

B. Enables the nurse to prescribe the appropriate medications: Nurses do not prescribe medications; that is the responsibility of physicians, nurse practitioners, or other prescribers. However, gathering client information is essential for providing accurate information to the prescriber, assisting in medication management, and monitoring for side effects.

C. Enables the nurse to modify behaviors related to personality disorders: While nurses can assist in the management of behaviors related to mental health conditions, the primary purpose of gathering client information is not to modify behaviors related to personality disorders. It is more about understanding the client's needs and tailoring care accordingly.

D. Enables the nurse to make sound clinical judgments and plan appropriate care: This is the correct answer. Gathering client information is a fundamental step in the nursing assessment process. It provides the necessary data for the nurse to make informed clinical judgments, identify health problems, and plan appropriate care interventions. It allows the nurse to understand the client's unique needs, preferences, and potential risks, leading to individualized and effective care planning.

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Correct Answer is B

Explanation

A. "The voices talk only at night when I'm trying to sleep."

This statement does not necessarily indicate a direct threat to the patient or others. It may be a manifestation of hallucination, but it doesn't explicitly pose a danger.

B. "The voices say everyone is trying to kill me."

This statement suggests paranoid delusions and a direct threat to the patient's safety. The nurse should implement safety measures to protect the patient and others from potential harm.

C. "I hear angels playing harps."

This statement describes a positive or benign hallucination, which may not require immediate safety measures. While it might be distressing for the patient, it doesn't pose an imminent danger.

A. A nurse asks a client if they have any cultural beliefs the nurse needs to be aware of B. A nurse tells a client about the nurse's own cultural background. C. A nurse observes a client's actions and reports they do not see any cultural practices D. A nurse checks a client's chart for any notes on culture

Correct Answer is A

Explanation

A. A nurse asks a client if they have any cultural beliefs the nurse needs to be aware of: This example demonstrates cultural competence as the nurse is actively seeking information about the client's cultural beliefs, practices, and preferences. It reflects an understanding that cultural factors can influence healthcare and the client-nurse relationship.

B. A nurse tells a client about the nurse's own cultural background: While sharing cultural information can be a part of building rapport, the focus of cultural competence is on understanding and respecting the client's cultural background, not necessarily sharing the nurse's own cultural background.

C. A nurse observes a client's actions and reports they do not see any cultural practices: This approach is limited, as cultural practices may not always be visible or evident in a clinical setting. Cultural competence involves actively seeking information from the client rather than making assumptions based on observations.

D. A nurse checks a client's chart for any notes on culture: While reviewing a client's chart for cultural information is part of cultural competence, it is not a complete approach. Direct communication with the client about their cultural beliefs and preferences is essential for a comprehensive understanding.

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What is the purpose of a nurse gathering client information?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which hallucination necessitates the nurse to implement safety measures? The patient says.

Correct Answer is B

Explanation

A nurse is describing the concept of cultural competence to a newly licensed nurse. Which of the following examples should the nurse include?

Correct Answer is A

Explanation

A nurse is discussing the use of mechanical restraints with a newly licensed nurse. Which of the following situations should the nurse include as an indication for placing a client in mechanical restraints?

A client is diagnosed with bipolar I disorder: manic episode. Which nursing intervention would be implemented to achieve the outcome of Client will gain 2 pounds by the end of the week?

What is being assessed when a nurse asks a client to identify name date, residential address, and situation?

How does a democratic form of self-government in the milieu contribute to client therapy?

A nurse is planning care for a client who has paranoid schizophrenia. Which of the following interventions should be included in the plan of care?

A client diagnosed with brief psychotic disorder tells a nurse about voices telling him to kill the president. Which nursing diagnosis should the nurse prioritize for this client?