Author Question: The community psychiatric nurse makes a home visit to see a client who is scheduled to receive home ... (Read 179 times)

lunatika · **on:** Jul 19, 2018

The community psychiatric nurse makes a home visit to see a client who is scheduled to receive
home care.

The nurse notes the client and family make poor eye contact and that the client and all
members of the family deferred to the father to answer questions during the visit. In what sphere
does the explanation for this observation probably reside?
a. Physical
b. Cultural
c. Environmental
d. Psychopathological

Question 2

A client with fluctuating levels of awareness, confusion, and disturbed orientation shouts The bugs,
they are crawling on my legs Get them off me The nurse can assess this behavior as indicating
that the client is experiencing

a. aphasia.
b. dystonia.
c. tactile hallucinations.
d. mnemonic disturbance.

sokh · **Reply #1 on:** Jul 19, 2018

Answer to Question 1

ANS: B
Eye contact and family patterns of authority are often culturally determined. The other options are
much less likely to provide a plausible explanation of the observation. Option A: All parties are
physically able to communicate. Option C: The environment is identical for all possible speakers.
Option D: No mention of psychopathology for any family members is given.

Answer to Question 2

C
The client feels bugs crawling on her legs, even though no sensory stimulus is actually present. This
description coincides with the definition of a hallucination, a false sensory perception. Tactile
hallucinations may be part of the symptom constellation of delirium. Option A: Aphasia refers to a
speech disorder. Option B: Dystonia refers to excessive muscle tonus. Option D: Mnemonic
disturbance is associated with dementia rather than delirium.