Client: Sarah Lopez, 32 years • Setting: Outpatient Mental Health Clinic
Client Record
0830 — Client arrived to clinic ambulatory, accompanied by partner. States “abdominal pain every day,” nausea, and fatigue for more than 12 months. Reports multiple prior evaluations without diagnosis. Requests additional testing.
Pain is diffuse, constant, non-radiating, rated 8/10. Symptoms worsen with stress and poor sleep. Denies fever, vomiting, diarrhea, hematemesis, melena, weight loss, dysuria, or hematuria. Reports intermittent palpitations.
Orientation: alert and oriented ×3. Speech rapid with detailed descriptions of symptoms. Affect anxious. Eye contact intermittent.
Safety: denies suicidal or homicidal ideation. No hallucinations endorsed.
Vital signs: T 98.4°F, HR 92/min, RR 18/min, BP 118/74, SpO₂ 99% RA.
Abdomen: soft, nondistended; bowel sounds normoactive; no guarding or rebound; mild diffuse tenderness to light palpation.
Click one option from the answer bank, then click the correct Bow Tie box.
Actions to Take
Action to Take
Action to Take
Potential Condition
Potential Condition
Parameters to Monitor
Parameter to Monitor
Parameter to Monitor
Actions
Validate the client’s symptoms and provide reassurance.
Discuss stress, sleep, coping strategies, and follow-up care.
Tell the client symptoms are not real because tests are normal.
Recommend emergency surgery evaluation.
Potential Conditions
Somatic symptom disorder
Delirium
Acute abdomen
Substance-induced psychosis
Monitor
Anxiety level and functional impairment.
Safety risk including suicidal ideation.
Signs of alcohol withdrawal.
Hallucinations as the primary finding.
Rationale
Step 1 — Identify the Clinical Pattern
The client presents with chronic abdominal pain, nausea, fatigue, repeated negative diagnostic evaluations, high anxiety, and excessive focus on physical symptoms for more than 12 months. Symptoms worsen with stress and poor sleep, which strongly supports somatic symptom disorder.
Vital signs are stable, laboratory studies are normal, imaging is negative, and there are no findings consistent with acute physiological instability.
Step 2 — Eliminate Incorrect Conditions
❌ Delirium
Eliminate because the client is alert and oriented ×3 without acute confusion or fluctuating consciousness.
❌ Acute Abdomen
Eliminate because the abdomen is soft without guarding, rebound tenderness, fever, or abnormal imaging.
❌ Substance-Induced Psychosis
Eliminate because the client denies substance use and demonstrates no hallucinations or disorganized thinking.
Step 3 — Prioritize Nursing Actions
The nurse should validate the client’s distress while avoiding reinforcement of unnecessary testing. Therapeutic communication, stress management, coping strategies, and follow-up care are priority interventions.
Validate the client’s distress without reinforcing an unconfirmed physical disease process.
Step 4 — Monitoring Priorities
Anxiety level
Functional impairment
Coping ability
Safety risk including suicidal ideation
NCLEX Clinical Judgment Principle
In somatic symptom disorder, symptoms are experienced as real by the client. The nurse acknowledges the distress while promoting coping strategies and functional improvement rather than repeated diagnostic testing without evidence of physiological disease.
