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 ["B","C","D","G","H","I"]
Explanation
Choice A rationale:
Financial situation is a concern but it does not require immediate follow-up in a medical context.
Choice B rationale:
Increased use of mood-altering substances is a serious concern. The client has been drinking heavily and asking for their “nerve” pill, which could indicate substance misuse.
Choice C rationale:
The client’s sexual behaviors, specifically having multiple partners and not using condoms, pose a risk for sexually transmitted infections.
Choice D rationale:
The positive Hepatitis Viral Study (HAA) indicates the presence of a viral hepatitis infection, which requires immediate medical attention.
Choice E rationale:
The BUN level is within the normal range (10 to 20 mg/dL), so it does not require immediate follow-up.
Choice F rationale:
The Hgb level is within the normal range (12 to 18 g/dL), so it does not require immediate follow-up.
Choice G rationale:
The sodium level is below the normal range (136 to 145 mEq/L), indicating hyponatremia, which requires immediate medical attention.
Choice H rationale:
The frequency of facility admissions indicates that the client’s condition is not being managed effectively and requires immediate reassessment.
Choice I rationale:
The recent loss of a parent is a significant life event that could exacerbate the client’s mental health issues and substance misuse, requiring immediate follow-up.
Correct Answer is D
Explanation
Choice A rationale:
Stopping medication can be a sign of non-compliance or dissatisfaction with treatment, but it is not a direct warning sign of suicide.
Choice B rationale:
Requesting an appointment to discuss depression is a positive step towards seeking help and managing mental health.
Choice C rationale:
Sleeping 12 hours a day could indicate depression or other mental health issues, but it is not a specific warning sign of suicide.
Choice D rationale:
Giving away possessions can be a warning sign of suicide as it might indicate that the person is putting their affairs in order, which is a serious suicide warning sign.
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