A nurse in a mental health facility is caring for a client.
Medical History: Antisocial personality disorder.
Substance use disorder.
Nurses' Notes:. 1400: Client admitted to facility by court order for evaluation following arrest for disorderly conduct and resisting arrest.
Client states, "That judge is so stupid.
I don't belong here!" Client has rigid posture, is pacing around the room attempting to intimidate staff and other clients on the unit.
Extra staff members gather.
1500: Client escorted to room.
Client becomes flirtatious with assistant personnel (AP). Client introduced to roommate, whom they ignore.
Continues to flirt with AP. 1800: Client refuses to go to dining room for dinner.
States, "I'm not sitting down with a bunch of nuts.
Bring my food to me!". For each potential nursing action, click to specify if the potential action is anticipated or contraindicated for the client.
Use bargaining to improve behavior.
Provide rewards for positive behavior.
Ignore negative behavior.
Maintain a low-stimuli environment.
The Correct Answer is B
Choice A rationale:
Using bargaining to improve behavior is not recommended for individuals with Antisocial Personality Disorder. It can reinforce manipulative behaviors.
Choice B rationale:
Providing rewards for positive behavior can be beneficial. It can encourage the development of healthier behaviors.
Choice C rationale:
Ignoring negative behavior is not recommended. It’s important to address these behaviors directly and establish clear consequences.
Choice D rationale:
Maintaining a low-stimuli environment can be beneficial for individuals with Antisocial Personality Disorder. It can help reduce agitation and aggressive behaviors.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Delusional disorder is characterized by the presence of one or more delusions for a month or longer, which could be plausible but are not real. This is not the case here.
Choice B rationale:
Anhedonia refers to the inability to experience pleasure, a common symptom in many mental disorders, including depression. It does not apply to this situation.
Choice C rationale:
Associative looseness, or loose associations, is a thought disorder characterized by speech in which ideas shift from one subject to another that is unrelated or minimally related. The client’s statement is an example of this.
Choice D rationale:
Hallucinations are sensory experiences that occur in the absence of actual stimulation. The client’s statement is not a hallucination, but a disorganized thought process.
Correct Answer is D
Explanation
Choice A rationale:
Drinking green tea does not directly cause lithium toxicity.
Choice B rationale:
Moderate exercise does not directly cause lithium toxicity.
Choice C rationale:
Increasing sodium intake does not directly cause lithium toxicity. In fact, a sudden decrease in sodium intake can increase the risk of lithium toxicity.
Choice D rationale:
Experiencing diarrhea can lead to dehydration, which increases the risk of lithium toxicity by reducing the excretion of lithium.
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