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.

Answer and Explanation

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

Explanation

Choice A rationale: The client’s magnesium level is 1.7 mg/dL, which is below the normal range of 1.8 to 2.4 mg/dL. Hypomagnesemia can cause neuromuscular irritability, muscle weakness, tremors, and even seizures or cardiac arrhythmias in severe cases.

It’s often associated with other electrolyte imbalances such as hypokalemia and hypocalcemia.

In the context of anorexia nervosa, this could be due to inadequate dietary intake, malabsorption, or excessive losses from the gastrointestinal tract.

Choice B rationale: The client’s chloride level is 98 mmol/L, which falls within the normal range of 96 to 106 mmol/L. Chloride is an important electrolyte that helps maintain acid-base balance, fluid balance, and is a component of gastric juice as hydrochloric acid.

There’s no immediate concern regarding the client’s chloride level.

Choice C rationale: The client’s phosphate level is 2.5 mg/dL, which is below the normal range of 2.8 to 4.5 mg/dL. Hypophosphatemia can lead to muscle weakness, bone pain, mental changes, and potentially life-threatening complications such as respiratory failure and heart failure.

In the context of anorexia nervosa, hypophosphatemia is a common complication during refeeding due to shifts in electrolytes.

Choice D rationale: The client’s potassium level is 3.5 mmol/L, which is at the lower end of the normal range of 3.5 to

5.0 mmol/L. Hypokalemia can cause muscle weakness, cramps, arrhythmias, and in severe cases, it can be life- threatening.

In the context of anorexia nervosa, this could be due to inadequate dietary intake, excessive losses due to vomiting or laxative abuse, or shifts in electrolytes during refeeding.

In conclusion, the nurse should follow up on the client’s magnesium, phosphate, and potassium levels due to their potential implications on the client’s health, especially considering the client’s current health status and the process of refeeding.

A. A client who has schizophrenia and is taking antipsychotic medication. B. An older adult client who has pancreatitis and is taking enzymes. C. An adult client who has type 2 diabetes mellitus and is taking insulin. D. A client who is in the third trimester of pregnancy and taking iron supplements.

Correct Answer is A

Explanation

Choice A rationale:

Antipsychotic medications are a class of drugs commonly used to treat schizophrenia and other psychotic disorders. They work by blocking dopamine receptors in the brain. However, dopamine is also involved in motor control, and blocking its receptors can lead to extrapyramidal symptoms (EPS).

EPS are a group of movement disorders that can be caused by antipsychotic medications. They include: Akathisia: A feeling of restlessness and an inability to sit still.

Dystonia: Involuntary muscle contractions that can cause twisting or spasms.

Parkinsonism: Symptoms similar to Parkinson's disease, such as tremor, rigidity, and slowness of movement. Tardive dyskinesia: Involuntary, repetitive movements of the face, tongue, or other body parts.

The risk of developing EPS is higher with older antipsychotic medications, such as haloperidol and chlorpromazine. Newer antipsychotic medications, such as risperidone and olanzapine, are less likely to cause EPS, but they can still occur.

Clients who are taking antipsychotic medications should be monitored for EPS. If EPS develop, the medication may need to be changed or the dose reduced.

Choice B rationale:

Enzymes are not known to cause EPS. They are used to treat pancreatitis by helping the body to digest food.

Choice C rationale:

Insulin is not known to cause EPS. It is used to treat type 2 diabetes mellitus by helping the body to control blood sugar levels.

Choice D rationale:

Iron supplements are not known to cause EPS. They are often taken by pregnant women to prevent iron deficiency anemia.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Explanation

A nurse is reviewing the medical histories of four clients.Which of the following clients may develop extrapyramidal symptoms from medication therapy?

Correct Answer is A

Explanation

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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?