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 A

Explanation

A. Self-destructive behavior despite alternative interventions: Mechanical restraints may be considered when a client poses an immediate risk of harm to themselves, and alternative interventions have been ineffective or are not feasible.

B. Discipline for throwing objects at staff: Mechanical restraints are not appropriate as a form of discipline. Restraints should only be used when there is an imminent risk of harm to the client or others.

C. Punishment for verbally abusing other clients: The use of restraints as a form of punishment is not ethical or appropriate. Restraints should be employed solely to prevent harm, not as a disciplinary measure.

D. Coercion to take prescribed medications: Coercion to take medications is not a valid reason for using mechanical restraints. Alternative approaches, such as therapeutic communication or discussing the need for medications with the client, should be explored.

A. "The voices talk only at night when I'm trying to sleep." B. The voices say everyone is trying to kill me. C. I hear angels playing harps

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.

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What is the purpose of a nurse gathering client information?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is A

Explanation

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

Correct Answer is B

Explanation

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

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A nurse instructs a patient taking a drug that inhibits monoamine oxidase (MAO) to avoid certain foods and drugs because of the risk of:

A nurse on an inpatient psychiatric unit implements care by scheduling client activities, interacting with clients, and maintaining a safe therapeutic environment. These actions reflect which role of the nurse?

A nurse is caring for a client who has schizophrenia and tells the nurse. "They lie about me all the time and they are trying to poison my food." Which of the following statements should the nurse make?

A 19 year old patient has a diagnosis of Borderline personality disorder. The patient approaches the nurse and shows multiple fresh cuts on both arms. Which is the most therapeutic response by the nurse?

A withdrawn client diagnosed with schizophrenia expresses little emotion and refuses to attend group therapy. What altered component of the nervous system should a nurse recognize as being implicated in this behavior?

A client diagnosed with obsessive-compulsive disorder is admitted to a psychiatric unit. The client has an elaborate routine for toileting activities. Which would be an appropriate initial client outcome during the first week of hospitalization?