A client tells the RN that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. What is the pri
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A client tells the RN that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. What is the priority nursing problem admission to the psychiatric unit?
A. Ineffective sexual patterns
B. Impaired environmental interpretation
C. Disturbed sensory perception
D. Compromised Family Coping - Answer>>> A. Ineffective sexual patterns
A female victim of sexual assault is being seen in the crisis center. The client states that she still feels "as though the rape just happened yesterday," even though it has been a few months since the incident. The appropriate nursing response is which of the following?
A) "You need to try and be realistic. The rape did not just occur."
B) "It will take some time to get over these feelings about your rape."
C) "Tell me more about the incident that causes you to feel like the rape just occurred."
D) "What do you think that you can do to alleviate some of your fears about being raped again?" - Answer>>> C) "Tell me more about the incident that causes you to feel like the rape just occurred."
The RN documents the mental status of a female client who has been hospitalized for several days by court order. The client states" I don't need to be here," and tells the RN that she believes that the T.V. talks to her. The RN should document these assessment statements in which section of the mental status exam?
A. Insight and judgement.
B. Mood and affect.
C. Remote memory.
D. Level of concentration. - Answer>>> A. Insight and judgement.
An older man with a hx of falls at home tells the clinic nurse that his son, who was incarcerated last year for assault and battery, has become abusive since his release from prison. Which intervention is most important for the nurse to implement?
A. Tell the client to call Adult Protective Services if his son's abuse continues.
B. Refer the client to a program for victims of domestic violence
C. Verify the client's report by determining if there is physical evidence of abuse
D. Assist the client in developing an emergency safety plan - Answer>>> C. Verify the client's report by determining if there is physical evidence of abuse
A female client on a psychiatric unit is sweating profusely while she vigorously does push-ups and then runs the length of the corridor several times before crashing into furniture in the sitting room. Picking herself up, she begins to toss chairs aside, looking for a red one to sit in. When another client objects to the disturbance, the client shouts, "I am the boss here. I do what I want." Which nursing problem best supports these observations?
A. Deficient diversional activity related to excess energy level.
B. Risk for other related violence related to disruptive behavior.
C. Risk for activity intolerance related to hyperactivity.
D. Disturbed personal identity related to grandiosity. - Answer>>> B. Risk for other related violence related to disruptive behavior.
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