A male client tells the nurse 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. Which is the priority nursing problem for admission to the psychiatric unit?
A.
Compromised family coping.
B.
Ineffective sexual patterns.
C.
Impaired environmental interpretation.
D.
Disturbed sensory perception.
The correct answer and Explanation is :
The priority nursing problem for this client is:
C. Impaired environmental interpretation.
Explanation:
The client’s claims of having an IQ of 400+, being a genius and an inventor, and being married to a movie star suggest a possible disconnection from reality. His report that his brother wants a sexual relationship with his wife could be indicative of paranoid delusions. These statements imply a distortion in how the client interprets his environment and the people around him.
Impaired environmental interpretation involves difficulties in perceiving or making sense of the reality of one’s surroundings. In this case, the client’s grandiose and paranoid beliefs could reflect a significant disturbance in how he processes and interprets information about his world. This issue is a priority because it can affect his safety, relationships, and overall functioning.
Disturbed sensory perception (Option D) could be relevant if the client were experiencing hallucinations or altered sensory experiences. However, the described symptoms are more consistent with delusional thinking rather than sensory distortions.
Compromised family coping (Option A) and Ineffective sexual patterns (Option B) might be relevant issues, but they are secondary to the immediate concern of the client’s impaired reality testing. Addressing impaired environmental interpretation is crucial to ensuring that the client is safe and can engage effectively in treatment. The primary goal in this context is to assess and manage any psychotic symptoms or delusions to stabilize the client and address their safety and psychiatric needs.