A 32-year-old male client with a history of arrests and substance use is admitted to the psychiatric unit for court-mandated evaluation. During the assessment, he is superficially charming, manipulates staff to get privileges, violates unit rules without remorse, and blames others for his behavior. Which of the following nursing interventions is most appropriate for managing this client?

Provide consistent structured rules and set firm limits on behavior.

Use sympathy and reassurance to reduce the client’s resistance to authority.

Allow the client flexibility in decision-making to encourage independence and self-direction.

Develop a close, personal rapport with the client to build trust and encourage emotional expression.

Answer and Explanation

The Correct Answer is A

Choice A reason: Consistent rules and firm boundaries are essential when working with individuals who display antisocial traits. Structure minimizes opportunities for manipulation and helps maintain safety and fairness on the unit.

Choice B reason: Offering sympathy and reassurance may reinforce manipulative behavior and undermine professional boundaries. It does not address the core issue of rule violation and lack of accountability.

Choice C reason: Allowing too much flexibility may increase opportunities for the client to exploit staff and disregard rules. This approach is counterproductive when dealing with manipulative behaviors.

Choice D reason: Developing a close, personal rapport risks blurring professional boundaries. Clients with these traits may exploit such relationships to gain privileges, which can disrupt treatment and unit structure.

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Correct Answer is D

Explanation

Choice A reason: Focusing only on medications neglects the interpersonal development central to Peplau’s model. The orientation phase emphasizes relationship building, not task-centered care.

Choice B reason: Allowing expression without structure or guidance does not fulfill the orientation phase, which requires the nurse to actively build trust and clarify roles.

Choice C reason: Excessive distance prevents rapport, which is essential in the orientation phase where the foundation for a therapeutic relationship must be established.

Choice D reason: Establishing trust, being consistent, and clarifying client expectations define the orientation phase of Peplau’s theory. This phase sets the groundwork for collaboration and progress in treatment.

A. "It sounds like you’re concerned about your privacy." B. "The CIA is prohibited from operating in health care facilities." C. "Let’s talk about something other than the CIA." D. "You have lost touch with reality, which is a symptom of your illness."

Correct Answer is A

Explanation

Choice A reason: This response acknowledges the patient’s feelings without confirming or denying the delusion. It helps establish trust while maintaining therapeutic communication. By focusing on the patient’s underlying concern, it avoids reinforcing the delusional content.

Choice B reason: Stating that the CIA is prohibited in health care facilities engages with the delusion, which is non-therapeutic because it validates the false belief.

Choice C reason: Redirecting away from the delusion may seem dismissive and does not address the patient’s immediate feelings of fear or concern. This could cause the patient to feel unheard.

Choice D reason: Telling the patient they have “lost touch with reality” is confrontational and could increase defensiveness. It is not supportive or therapeutic in building rapport.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse practicing Peplau’s Relations Theory is working with a newly admitted client who is withdrawn and reluctant to engage. According to Peplau’s working model, which nurse action best explains the orientation phase of the nurse-client relationship?

Correct Answer is D

Explanation

A patient diagnosed with schizophrenia tells the nurse, "The CIA is monitoring us through the fluorescent lights in this room. Be careful what you say." Which response by the nurse would be most therapeutic?

Correct Answer is A

Explanation

A client receiving a first-generation antipsychotic develops symptoms of acute dystonia, including muscle spasms and neck stiffness. Which type of medication should the nurse anticipate administering to manage these side effects?

A nurse is caring for a child whose guardians report that the child is consistently unable to speak during class and other social situations. The nurse should identify that the child is experiencing which of the following anxiety disorders?

A nurse physically restrains a mentally ill client without obtaining proper consent or a physician's order, despite the client not posing an immediate threat to self or others. Which intentional tort could the nurse potentially be liable for?

A 52-year-old male with a long history of alcohol use disorder is admitted to the hospital and begins showing signs of Delirium Tremens, including agitation, tremors, tachycardia, and hallucinations. Which medication should the nurse anticipate administering to manage these symptoms?

A nurse is teaching a client at a prenatal clinic. The client shares that they have family members diagnosed with schizophrenia and wants to know how they can reduce their baby's risk of developing schizophrenia. Which of the following information should the nurse include?