A nurse is conducting a mental status assessment and asks the client if he has experienced any command hallucinations. The client asks for an explanation of the term, and then denies that he hears voices telling him what to do.
The nurse is not sure that he is telling the truth. What would keep a client from sharing this information with the nurse? Select all that apply. A) Social desirability bias
B) Lack of trust in the nurse
C) Wish for hospital admission
D) Wish for hospital discharge
E) Wish for reduction in severity of criminal penalties
Question 2
A client on the psychiatric unit tells the nurse that someone has put poison in the food and she wants the nurse to warn everyone not to eat today.
When the lunch trays arrive, the client becomes very agitated and starts walking around trying to knock the food out of other clients' hands. The client is taken to her room where she accuses the nurse and staff of being involved in a plot to kill her. She does accept an IM injection that calms her and she goes to sleep. Which nursing diagnosis did the nurse document? A) Alterations in thought (delusions) related to concern for others and powerlessness
B) Alterations in nutrition (impaired) related to belief that the food is poisoned (persecution)
C) Potential for harm (self and others) related to fear of being poisoned; (persecution)
D) Altered perceptions related to misinterpretation of the environment, cognitive impairment
The nurse is using Standard Precautions to draw blood.
Head To Toe Assessment
Assessment of Aphasia
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Example of simplified note for one-time client.