A nurse is assessing a client who has antisocial personality disorder. Which of the following manifestations should the nurse expect?

Self-mutilation

Social isolation

Paranoid ideation

Lack of empathy

Answer and Explanation

The Correct Answer is D

Rationale:

A. Self-mutilation: This behavior is more commonly associated with borderline personality disorder. Individuals with borderline traits may engage in self-harm as a means of emotional regulation or response to abandonment fears, not typical in antisocial personality disorder.

B. Social isolation: Clients with antisocial personality disorder are often socially manipulative and may actively engage with others for personal gain. They are typically not socially withdrawn but can be superficially charming and exploitative.

C. Paranoid ideation: Paranoia is more closely linked with paranoid or schizotypal personality disorders. While someone with antisocial traits may be suspicious if it serves their manipulative purposes, persistent paranoid ideation is not a defining feature.

D. Lack of empathy: A hallmark feature of antisocial personality disorder is a disregard for others' feelings, rights, and safety. These clients often exhibit a lack of remorse and empathy, making them prone to violating social norms and laws without guilt.

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

Explanation

Rationale:

A. Provide a quiet environment for the client: Minimizing noise and stimulation helps reduce stress and prevents spikes in intracranial pressure (ICP). A calm environment is essential for neurologically compromised clients.

B. Encourage the client to cough and deep breathe: Coughing can increase thoracic pressure and, consequently, ICP. In clients with elevated ICP, activities that increase intrathoracic or intra-abdominal pressure should be avoided to prevent worsening brain injury.

C. Obtain client vital signs every 8 hr: Clients with increased ICP require frequent monitoring, often hourly or every 2–4 hours, to detect changes in neurologic status or signs of Cushing's triad. Every 8 hours is insufficient for early intervention.

D. Maintain the head of the bed at a 30 degree angle: Elevating the head promotes venous outflow from the brain without compromising perfusion. A 30-degree elevation is a commonly recommended position to help control ICP levels.

E. Administer stool softeners to the client: Straining during bowel movements increases intra-abdominal pressure and can elevate ICP. Stool softeners reduce this risk and are a supportive intervention in the management of increased ICP.

A. Administer magnesium sulfate to the client. B. Administer betamethasone to the client. C. Monitor the client's temperature every 2 hr. D. Monitor fetal heart rate every 4 hr.

Correct Answer is C

Explanation

Rationale:

A. Administer magnesium sulfate to the client: Magnesium sulfate is typically used for neuroprotection before 32 weeks or to manage preeclampsia; it is not indicated for rupture of membranes at 36 weeks unless there are other risk factors.

B. Administer betamethasone to the client: Betamethasone is used to enhance fetal lung maturity, most beneficial before 34 weeks. At 36 weeks, the lungs are usually mature enough that corticosteroids are not routinely indicated.

C. Monitor the client's temperature every 2 hr: This helps detect early signs of chorioamnionitis, a serious infection risk after membrane rupture, especially with prolonged rupture.

D. Monitor fetal heart rate every 4 hr: Fetal heart monitoring should be more frequent in the presence of membrane rupture to promptly identify signs of distress or infection, not every 4 hours.

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A nurse is assessing a client who has antisocial personality disorder. Which of the following manifestations should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has increased intracranial pressure following a traumatic brain injury. Which of the following actions should the nurse take? (Select all that apply.)

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

Explanation

A nurse is caring for a client who is 36 weeks of gestation and experiences a spontaneous rupture of membranes. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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