Author Question: A client with recurrent headaches has been told by the physician that the cause is likely ... (Read 64 times)

beccaep · **on:** Jul 19, 2018

A client with recurrent headaches has been told by the physician that the cause is likely psychosomatic.

The client reports this conversation to the nurse and says, That just can't be true My head hurts so bad sometimes that it makes me sick to my stomach. The nurse's best response is: A) To give the client some privacy and time to calm down
B) To say nothing and sit quietly with the client
C) To say, the pain in your head is very real
D) To say, well, that's not what your doctor thinks

Question 2

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?

A. Disturbed sensory perception
B. Altered thought processes
C. Risk for violence: directed toward others
D. Risk for injury

Benayers · **Reply #1 on:** Jul 19, 2018

Answer to Question 1

C
Feedback: The client is asking for some type of validation, and the nurse's best response is to validate the client's pain as real. In the situation presented, the client's headaches are very real to him and he needs to talk out his feelings regarding what the physician said. It is inappropriate to give the client time to calm down or to say nothing. Answer D would put the client on the defensive.

Answer to Question 2

C
The nurse should prioritize the diagnosis risk for violence: directed toward others. A client who hears voices telling him to kill someone is at risk for responding and reacting to the command hallucination. Other risk factors for violence include aggressive body language, verbal aggression, catatonic excitement, and rage reactions.