Created on02052018 page 38 detailed answer key mental

Created on:02/05/2018 Page 38

Detailed Answer Key
Mental Health Progression Practice
and therefore are not the priority concern.
C. Command hallucination
Rationale: Gustatory hallucinations are an important finding; however, they do not pose the greatest risk
and therefore are not the priority concern.
D. Tactile hallucination
Rationale: Tactile hallucinations are an important finding; however, they do not pose the greatest risk and
therefore are not the priority concern.
82.A nurse in an acute mental health facility is creating a plan of care for a new client who has histrionic personality
disorder. Which of the following is the priority intervention for the nurse to make?
C. Communicate with the client using concrete language.
Rationale: This is an appropriate intervention; however, it is not the priority for the client who has histrionic
personality disorder.
D. Demonstrate assertive behavior.
Rationale: This is an appropriate intervention; however, it is not the priority for the client who has histrionic
personality disorder.
83.A nurse is caring for a client who has delusional behavior and states, "I can't go to group therapy today. I am
expecting a high level official to visit me!" The nurse responds, "I understand, but it is time for group therapy and
we expect everyone to attend. Let's walk over together." For which of the following reasons is the nurse's
response considered therapeutic?