Which action is appropriate for the nurse when noticing a client's mood does not match their affect during an assessment?
Assume the client is not being truthful in their responses.
Ignore the observation as it is likely just the client’s current state.
Document the observation and continue assessing other areas.
Consider this as a potential sign of a mental health disorder and explore further.
The Correct Answer is D
Choice A reason: Assuming dishonesty is inappropriate and undermines therapeutic rapport. Mood–affect incongruence is often a clinical sign rather than intentional deception.
Choice B reason: Ignoring the observation dismisses important diagnostic information. Mood–affect mismatch can indicate underlying psychiatric conditions such as depression, bipolar disorder, or schizophrenia.
Choice C reason: Documentation is important but insufficient if not followed by further exploration. The nurse must investigate the clinical significance of the incongruence.
Choice D reason: Considering mood–affect mismatch as a potential sign of a disorder and exploring further is correct. This ensures accurate assessment, guides diagnosis, and informs appropriate interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Increasing medication without prescriber consultation is unsafe and violates scope of practice. It risks adverse effects and undermines collaborative care.
Choice B reason: Ignoring feelings invalidates the client’s experience and worsens anxiety. Therapeutic communication requires acknowledgment and support, not avoidance.
Choice C reason: Encouraging daily physical exercise tailored to interests is effective because it reduces anxiety through endorphin release, improves sleep, and enhances self-efficacy. Tailoring to interests increases adherence and enjoyment.
Choice D reason: Focusing solely on deep breathing is too narrow. While beneficial, anxiety management requires a multimodal approach including lifestyle, coping strategies, and psychosocial support.
Correct Answer is C
Explanation
Choice A reason: Family support is important but secondary. It contributes to coping and recovery but does not define the holistic assessment itself.
Choice B reason: The nurse’s emotional state may influence care delivery but is not a primary factor in assessing the client. The focus must remain on the client’s needs.
Choice C reason: Cultural and spiritual beliefs are central to holistic assessment. They shape the client’s understanding of mental health, coping strategies, and acceptance of interventions. Respecting these beliefs ensures care is relevant and effective.
Choice D reason: Financial status is a social determinant of health but not the primary factor in holistic assessment. It should be considered alongside cultural and spiritual beliefs, which more directly influence mental health perceptions and care engagement.
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