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 C

Explanation

Choice A rationale: Communicating empathy for the client’s feelings to increase rapport is an important aspect of nursing care. It helps in building a therapeutic relationship with the client, which can facilitate better communication and cooperation during treatment. However, while this is a valuable intervention, it does not take priority over monitoring for adverse effects of refeeding in a client diagnosed with anorexia nervosa who has begun to gain weight.

Choice B rationale: Helping the patient balance energy expenditure and caloric intake is a crucial part of the treatment plan for anorexia nervosa. This intervention aims to ensure that the client is receiving adequate nutrition for their body’s needs without excessive energy expenditure that could hinder weight gain. However, this intervention is not as immediate a priority as monitoring for refeeding syndrome, which can have severe and potentially life-threatening consequences.

Choice C rationale: Assessing for adverse effects of refeeding is the priority nursing intervention in this scenario. Refeeding syndrome is a serious and potentially life-threatening condition that can occur when nutritional replenishment is initiated in severely malnourished clients, such as those with anorexia nervosa. It is characterized by metabolic alterations, including hypophosphatemia, hypokalemia, and hypomagnesemia. These alterations can lead to serious complications, such as cardiac arrhythmias, respiratory failure, and neurological complications.

Therefore, early detection and management of refeeding syndrome are crucial.

Choice D rationale: Assessing for depression and anxiety during every shift assessment is an important part of psychiatric nursing care. Many individuals with anorexia nervosa also experience co-morbid psychiatric conditions, such as depression and anxiety disorders. Regular assessment can help detect any changes in the client’s mental status and prompt timely intervention. However, while this is an important aspect of care, it does not take priority over assessing for the adverse effects of refeeding.

A. Attention-seeking behaviors B. Electrolyte levels C. Presence of lanugo D. Signs of infection E. Frequency of compensatory behaviors.

Correct Answer is ["B","C"]

Explanation

Choice A rationale: Anorexia nervosa is an eating disorder characterized by relentless drive for thinness with a fear of gaining body weight associated with self-induced behaviors towards thinness. Symptoms include extreme weight loss, thin appearance, intense fear of gaining weight, bingeing and purging, abnormal blood counts, fatigue, insomnia, dizziness or fainting, bluish discoloration of the fingers, hair that thins, breaks or falls out, soft, downy hair covering the body, amenorrhea (absence of menstruation), constipation, dry or yellowish skin, intolerance of cold, irregular heart rhythms, low blood pressure, dehydration, osteoporosis, swelling of arms or legs. However, the client’s symptoms do not align with those of anorexia nervosa.

Choice B rationale: Bulimia nervosa is an eating disorder characterized by binge eating, followed by methods to avoid weight gain. Symptoms include binge eating, forceful vomiting, long-term fear of gaining weight, preoccupation with weight and body, a strong negative self-image, overuse of laxatives or diuretics, use of supplements or herbs for weight loss, excessive exercises, stained teeth (from stomach acid), calluses on the back of the hands, withdrawal from normal social activities. The client’s symptoms of using laxatives frequently and running for 1 hr after eating a very large meal, which happens at least 9 times a week, align with those of bulimia nervosa.

Choice C rationale: Histrionic personality disorder (HPD) is a mental health condition characterized by unstable emotions, a distorted self-image and a desire to be noticed. Symptoms include persistent attention seeking, dramatic behavior, rapidly shifting and shallow emotions, sexually provocative behavior, undetailed style of speech, and a tendency to consider relationships more intimate than they actually are. The client’s symptoms of feelings of anxiety and depression, starting smoking marijuana as that is what their “new friends do all the time”, and being recently arrested for stealing make-up from a local department store and acknowledging that this “is the first time I was caught” align with those of HPD.

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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

Which nursing intervention has priority as a client diagnosed with anorexia nervosa begins to gain weight after initiated therapy?

Correct Answer is C

Explanation

Correct Answer is ["B","C"]

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?