HESI NCLEX-RN 4th
Edition Mental Health
The nurse develops a plan of care for a client with
symptoms of paranoia and psychosis. The priority nursing
diagnosis is Impaired social interactions related to
inability to trust. Which intervention is most important for
the nurse to implement?
A.
Greet the client by first name during each social
interaction.
B.
Determine if the client is experiencing auditory
hallucinations.
C.
Introduce the client to peers on the unit as soon as
possible.
D.
Assign the client to a group about developing social skills.
- ANSWER-Correct Answer: A
Rationale:
The most important nursing intervention is to greet the
client by name (A) and provide short frequent contact to
establish trust. The presence of auditory hallucinations
can affect social interactions (B), but is not a priority
intervention. (C and D) are effective interventions after
individual rapport has been established with the client.
On admission, a highly anxious client is described as
delusional. Delusions are most likely to occur with which
disorder?
A.
Dissociative disorders
B.
Personality disorders
C.
Anxiety disorders
D.
Psychotic disorders - ANSWER-Correct Answer: D
Rationale:
Delusions are false beliefs characteristic of psychosis (D).
Delusions are generally not characteristic of (A, B, and C)
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