A client and their spouse come to talk with the nurse about their suspicion that the client may have intermittent explosive disorder after researching it on the internet. Which behaviors reported by the spouse indicate that the client may be experiencing this disorder? (Select all that apply.)

The explosive episode does not provide a feeling of relief in the client.

The spouse states that the client is mild-mannered and kind unless this occurs.

After having an explosive anger episode, the client was embarrassed and apologetic.

The client punched a hole in the wall and broke furniture during an episode.

The spouse states that the anger arises from something that is not even a big issue.

Answer and Explanation

Correct Answer : B,D,E

Choice A reason: Not feeling relief after an explosive episode can indicate that the behavior is not a controlled release of tension, which is characteristic of intermittent explosive disorder.

Choice B reason: Being mild-mannered and kind does not necessarily indicate intermittent explosive disorder; this behavior could be part of a normal range of personality traits.

Choice C reason: Feeling embarrassed and apologetic after an episode is common in intermittent explosive disorder, as individuals often regret their actions.

Choice D reason: Physical aggression, such as punching walls and breaking furniture, is a key indicator of intermittent explosive disorder.

Choice E reason: Anger that is disproportionate to the situation, especially over minor issues, is a hallmark of intermittent explosive disorder.

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Correct Answer is ["A","C","D","E"]

Explanation

Choice A Reason:

Checking the client's pupil reactivity is important because alcohol intoxication can affect the nervous system, which may be reflected in changes in pupil size and reactivity to light. Normal pupil size ranges from about 2 to 4 mm in diameter in bright light to 4 to 8 mm in the dark. Pupils that do not respond to light could indicate a neurological deficit that requires immediate attention.

Choice B Reason:

Performing a developmental screening test is not typically indicated for acute alcohol intoxication management. Developmental screenings are generally used to assess children for appropriate growth and developmental milestones, not for adults in an emergency setting due to intoxication.

Choice C Reason:

Preparing the client for a CT scan may be necessary if there is a suspicion of head trauma or intracranial bleeding, which can occur with falls or injuries associated with intoxication. A CT scan can help identify any urgent issues that need to be addressed.

Choice D Reason:

Obtaining a urine specimen can be useful for several reasons. It can be tested for the presence of alcohol, other substances, or toxins. Additionally, it can provide information about the client's overall health and kidney function.

Choice E Reason:

Monitoring the client’s vital signs frequently is crucial. Alcohol intoxication can lead to vital sign abnormalities such as hypotension, tachycardia, or respiratory depression. Normal ranges for vital signs vary but generally include a blood pressure of 90/60 mmHg to 120/80 mmHg, a heart rate of 60 to 100 beats per minute, and a respiratory rate of 12 to 20 breaths per minute.

A. Sharing personal feelings openly with the client B. Establishing boundaries for both the nurse and client C. Offering sound advice to the client D. Avoiding concern with whether the client likes the nurse E. Maintaining a client focus at all times

Correct Answer is ["B","D","E"]

Explanation

Choice A reason: Sharing personal feelings openly with the client can blur the professional boundaries necessary for a therapeutic relationship and is not typically encouraged.

Choice B reason: Establishing boundaries is crucial in maintaining a professional and therapeutic relationship, ensuring that both the nurse and client understand the limits and expectations of their interactions.

Choice C reason: While offering advice can be part of the therapeutic process, it is more important for the nurse to guide clients in finding their own solutions rather than providing direct advice.

Choice D reason: A therapeutic relationship should be professional and not based on personal feelings. The nurse's concern should be on the client's well-being rather than being liked.

Choice E reason: Maintaining a client focus at all times ensures that the care provided is centered on the client's needs, which is essential in a therapeutic relationship.

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A client and their spouse come to talk with the nurse about their suspicion that the client may have intermittent explosive disorder after researching it on the internet. Which behaviors reported by the spouse indicate that the client may be experiencing this disorder? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in the emergency department is creating a plan of care for a client experiencing alcohol intoxication. Which of the following interventions should the nurse plan to include? Select all that apply.

Correct Answer is ["A","C","D","E"]

Explanation

The nurse maintains a therapeutic relationship with several clients on the behavioral health unit. Which characteristics will be most important for the nurse to foster to maintain these relationships? Select all that apply.

Correct Answer is ["B","D","E"]

Explanation

The nurse is talking with a client who grew up in a home where both parents were alcoholics. Which behaviors does the nurse identify when assessing this client that correlate with this home life? Select all that apply.

The nurse is attempting to develop empathy for a client but is not completely feeling empathetic. Which factor might be hindering the nurse from developing empathy for this client?

A client diagnosed with bulimia nervosa has been attending a mental health clinic for several months. Which factor should the nurse identify as an appropriate indicator of a positive client behavioral change?

A client has a history of excessive fear of water. Which term should the nurse use to describe this specific phobia, and under what subtype is this phobia identified?

The nurse is performing an assessment for a young adolescent and observes a lack of hair on the eyebrows and the hairline. Which statement made by the parent demonstrates an understanding of the type of hair loss the child is experiencing?

The nurse is working to develop a therapeutic nurse-client relationship with a client diagnosed with paranoid personality disorder. Which techniques will the nurse use to foster trust? Select all that apply.