Author Question: The data element obtained during nursing assessment that supports the presence of a fugue state is ... (Read 71 times)

azncindy619 · **on:** Jul 19, 2018

The data element obtained during nursing assessment that supports the presence of a fugue state is
that the client states he

a. cannot recall why he is living in his present location.
b. feels as if he is living in a fuzzy dream state.
c. feels very anxious about his problems.
d. feels that different parts of him are at war.

Question 2

The client, a newly arrived Russian immigrant, was admitted to the mental health unit after creating
a disturbance in a church while a funeral was taking place.

During the admission interview he is
loud, mixes English and Russian phrases, and makes gestures such as vigorously shaking his fist.
The nurse responsible for admitting him should
a. tell him she is going to ask him some questions that he must try to answer in
English.
b. defer the nursing admission interview until after the client has calmed down.
c. request the assistance of a security guard.
d. request the assistance of an interpreter.

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

Answer to Question 1

ANS: A
The client in a fugue state frequently relocates and assumes a new identity while not recalling his
previous identity or where he lived in the past. Option B is more consistent with depersonalization
disorder. Option C is consistent with generalized anxiety disorder. Option D is consistent with
feelings experienced with dissociative identity disorder.

Answer to Question 2

ANS: D
A psychotic client who is mixing English and his or her native language cannot be accurately
assessed by an English-speaking nurse who does not speak the other language. The care plan should
be based on accurate assessment data; hence calling for an interpreter is necessary and expedient.
Most hospitals have a list of individuals who are fluent in various languages and are willing to assist
the medical staff. Option A will not produce the desired result if the client is disorganized and
unable to comply. Option B: Assessment information is necessary to obtain if at all possible.
Deferring the interview should not be an initial option. Option C: Data do not suggest the client is
aggressive, although fist-shaking might be interpreted as aggressive in some cultural contexts.