Page 2293 - Saunders Comprehensive Review For NCLEX-RN

asking another person to escort the client out of the session is inappropriate. This
may agitate the client and escalate the client’s behavior further. Barring the client
from group sessions is also an inappropriate action because it violates the client’s
right to receive treatment and is a threatening action.
Test-Taking Strategy: Note the strategic word, initially. Eliminate options that are
comparable or alike and relate to the client leaving the session. Next, eliminate the
option that violates the client’s right to receive treatment and is a threatening action.
Remember that setting firm limits with the client initially is best.
Level of Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Mental Health
Health Problem: Mental Health: Mood Disorders
Priority Concepts: Caregiving; Psychosis
Reference: Varcarolis (2017), pp. 232-233.

809. Answer: 3

Rationale: A conversion disorder is the alteration or loss of a physical function
that cannot be explained by any known pathophysiological mechanism. A
conversion disorder is thought to be an expression of a psychological need or
conflict. In this situation, the client witnessed an accident that was so psychologically
painful that the client became blind. Psychosis is a state in which a person’s mental
capacity to recognize reality, communicate, and relate to others is impaired,
interfering with the person’s ability to deal with life’s demands. Repression is a
coping mechanism in which unacceptable feelings are kept out of awareness. A
dissociative disorder is a disturbance or alteration in the normally integrative
functions of identity, memory, or consciousness.
Test-Taking Strategy: Focus on the subject, the cause of acute blindness. The key
to the correct option lies in the fact that the client presents no organic reason to
account for the blindness—hence, a conversion disorder.
Level of Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process—Planning
Content Area: Mental Health
Health Problem: Mental Health: Somatization disorder
Priority Concepts: Caregiving; Psychosis
Reference: Varcarolis (2017), pp. 154-155.

810. Answer: 3

Rationale: The client is at risk for injury to self and others and should be escorted
out of the dayroom. Seclusion is premature in this situation. Telling the client that
the behavior is inappropriate has already been attempted by the nurse. Denying
privileges may increase the agitation that already exists in this client.
Test-Taking Strategy: Eliminate option 2 because this intervention has already
been attempted. Next, use Maslow’s Hierarchy of Needs theory to answer the

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