The nurse is completing the psychosocial history on a newly ...

[gbarreiro]

The nurse is completing the psychosocial history on a newly admitted adult client. The client reports trouble concentrating, rapid heartbeats, irritability, and inability to make decisions. Based on these assessment findings, which does the nurse suspect?
 
  1. A stress reaction.
  2. Role confusion.
  3. An impending heart attack.
  4. Dysfunctional anxiety.

Question 2

While being interviewed, a client admits to the nurse that she has been hearing voices and sounds for the past three days.
 
  Which response by the nurse is the most appropriate?
  1. How long have you been hearing these voices?
  2. Tell me about what the voices tell you to do.
  3. These must be other things you are hearing.
  4. Do the voices bother you during the night only?

[mathjasmine]

Answer to Question 1

Correct Answer: 1

A high level of stress may result in symptoms such as irritability, indecisiveness, confusion, pounding heart or pulse, and trouble concentrating, among other symptoms. There are no data to support the concern of role confusion. Symptoms of an impending heart attack may include irritability, confusion, and a pounding heart rate, but there are other more classic symptoms that typically also appear. Symptoms of anxiety include some of the above symptoms, but there is not enough evidence to call it dysfunctional.

Answer to Question 2

Correct Answer: 2

The most appropriate next question after the client tells the nurse she hears voices is asking the client if the voices tell her what she must do. Command hallucinations are dangerous and may lead to self-destructive behavior or harm to other people or property. Knowing the length of time a person has had auditory hallucinations is helpful but is not the most important next question. Also, the client already said that she had been hearing the voices for 3 days. Telling the client that there cannot be voices may indicate your lack of belief regarding in what is being said. This may cause refusal to answer additional questions. Asking whether or not the voices are bothersome to the client only at night does not yield helpful information, as hallucinations are not a normal phenomenon and treatment goals would include eliminating the hallucinations. Additionally, the goal of the interview is to obtain the information most important to the treatment plan and is not to dwell on the hallucinations, thereby reinforcing them to the patient.