A mental health nurse is caring for a client with Antisocial Personality Disorder who attacked one of her friends and is admitted to the psychiatric unit.
Which of the following actions should the nurse take first?
Explain to the client that the behavior was unacceptable.
Set behavioral limits for the client.
Explore the truth of the client's statements.
Establish a client relationship.
The Correct Answer is D
Rationale for Choice A:
While it is important to address the client's behavior, simply explaining that it was unacceptable is unlikely to be effective in this situation. Clients with antisocial personality disorder often have difficulty understanding and accepting responsibility for their actions. They may lack empathy for others and may not see their behavior as problematic. Confronting the client about their behavior too early in the therapeutic relationship could lead to defensiveness, hostility, or even aggression. It is important to first establish a rapport with the client and build a foundation of trust before addressing difficult topics.
Rationale for Choice B:
Setting behavioral limits is an important aspect of treatment for clients with antisocial personality disorder. However, it is not the first priority in this situation. Before setting limits, the nurse needs to establish a relationship with the client and assess their individual needs and level of functioning. Attempting to set limits without first establishing a rapport could lead to power struggles and further resistance from the client.
Rationale for Choice C:
Exploring the truth of the client's statements may be necessary at some point in the treatment process. However, it is not the first priority in this situation. The nurse's initial focus should be on establishing a relationship with the client and assessing their immediate needs. Focusing on the accuracy of the client's statements too early in the therapeutic process could derail the development of a trusting relationship.
Rationale for Choice D:
Establishing a client relationship is the first and most important step in the treatment of any client, but it is especially crucial for clients with antisocial personality disorder. These clients often have difficulty trusting others and forming close relationships. By establishing a rapport with the client, the nurse can begin to build trust and create a safe and supportive environment. This foundation is essential for any further therapeutic interventions to be successful.
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Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Planning a therapeutic diet for the client is not the first priority. While a therapeutic diet may be necessary at some point, it is important to first assess the client's nutritional status to determine their individual needs. A diet plan that is not tailored to the client's specific needs could be ineffective or even harmful.
Focusing on diet planning prematurely could also reinforce the client's distorted body image and eating disorder behaviors. It is important to address the underlying psychological issues before implementing dietary interventions.
Choice C rationale:
Requesting a mental health consult is important, but it is not the first priority. The nurse should first gather data about the client's nutritional status to provide the mental health professional with a comprehensive understanding of the client's condition.
A mental health consult can be helpful in addressing the client's distorted body image and underlying psychological issues, but it should not take precedence over assessing and addressing the client's immediate physical needs.
Choice D rationale:
Providing a structured environment for the client can be helpful in managing eating disorders, but it is not the first priority. The client's immediate physical needs, such as nutritional status, should be addressed first.
A structured environment may include regular mealtimes, supervision during meals, and restrictions on activities that could be used to compensate for food intake (such as excessive exercise). However, these interventions are more effective when implemented in conjunction with addressing the client's underlying psychological issues.
Choice B rationale:
Identifying the client's nutritional status is the first priority because it will provide essential information about the severity of the client's malnutrition and any potential medical complications. This information will guide the nurse in developing an appropriate plan of care, including dietary interventions, mental health referrals, and other necessary measures.
A thorough nutritional assessment should include:
A review of the client's dietary intake, including the types and amounts of foods consumed, as well as any restrictions or avoidance of certain foods.
A physical examination to assess for signs of malnutrition, such as muscle wasting, dry skin, hair loss, and edema. Laboratory tests to evaluate electrolyte levels, blood glucose levels, and other nutritional markers.
Correct Answer is ["A","D"]
Explanation
Choice A rationale: Fluoxetine, also known as Prozac, is a type of antidepressant known as a selective serotonin reuptake inhibitor (SSRI). It works by increasing the amount of serotonin, a natural substance in the brain that helps maintain mental balance. One of the common side effects of fluoxetine is a decreased interest in sexual intercourse. This can manifest as a decreased sex drive, difficulty in achieving an orgasm, or inability to have or keep an erection. It’s important for patients to be aware of this potential side effect so they can discuss it with their healthcare provider if it becomes a concern.
Choice B rationale: While fluoxetine is an effective treatment for depressive disorders, it does not typically cause an improvement in depressive symptoms in 2 to 3 days. In fact, it may take several weeks before patients begin to feel the full benefits of fluoxetine. Some people may even feel worse before they start to feel better. This is because it takes some time for fluoxetine to adjust the chemical balance in the brain.
Choice C rationale: Drooling is not typically associated with the use of fluoxetine. While fluoxetine can have many side effects, drooling is not commonly reported. If a patient experiences this side effect, it may be due to another medication or a different medical condition. It’s always important to discuss any new or unusual symptoms with a healthcare provider.
Choice D rationale: Loss of appetite is another potential side effect of fluoxetine. This can lead to weight loss in some patients. While this may be desirable for some, it can also lead to malnutrition and other health problems if not properly managed. Patients should be advised to monitor their weight and dietary intake while taking fluoxetine, and to discuss any concerns with their healthcare provider.
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