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A nurse is performing a mental status examination for a newly admitted client. Which of the following client behaviors indicates impaired reality testing?

A) Excessive talking and restlessness
B) Clear and coherent communication
C) Accurate perception of surroundings
D) Delusional beliefs and hallucinations

1 Answer

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Final answer:

Delusional beliefs and hallucinations are behaviors that indicate impaired reality testing during a mental status examination, as they show a detachment from actual environment and difficulty in accurately interpreting and responding to it.

Step-by-step explanation:

A nurse performing a mental status examination to assess a client's psychological functioning may observe various behaviors.

When evaluating for impaired reality testing, specifically, behaviors that are indicative include delusional beliefs and hallucinations, as this reflects a detachment from the actual environment and an inability to accurately interpret and respond to it.

Delusional beliefs are false beliefs held with a strong conviction despite superior evidence to the contrary, while hallucinations are perceptual experiences without a real external stimulus.

On the other hand, behaviors such as excessive talking and restlessness may indicate anxiety or mania, clear and coherent communication suggests intact mental function, and accurate perception of surroundings indicates an appropriate connection with reality.

Therefore, of the provided options, delusional beliefs and hallucinations represent impaired reality testing.

User Snehal Ghumade
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