A nurse is caring for a 22-year-old female client who has bulimia nervosa and frequently self-induces vomiting. Which of the following findings should the nurse expect? (SELECT ALL THAT APPLY)

The correct answer is b. It’s not my fault.

Choice A Reason: I just don’t remember doing it

This statement might be used by someone trying to avoid responsibility, but it is not as characteristic of antisocial personality disorder (ASPD) as outright denial of fault. Individuals with ASPD often exhibit a lack of accountability and may lie or manipulate to avoid consequences. However, claiming memory loss is less direct than denying responsibility altogether.

Choice B Reason: It’s not my fault

This statement is highly characteristic of antisocial personality disorder. Individuals with ASPD often refuse to take responsibility for their actions and may blame others or external circumstances. This lack of accountability and tendency to deflect blame is a core feature of the disorder, making this the most expected comment.

Choice C Reason: I’m really sorry about all the people I’ve hurt

This statement is unlikely for someone with antisocial personality disorder. People with ASPD typically lack empathy and remorse for their actions. Expressing genuine sorrow and concern for others is not consistent with the typical behavior of someone with this disorder.

Choice D Reason: I’m too ashamed to talk about it

This statement suggests a level of self-awareness and guilt that is not typical of antisocial personality disorder. Individuals with ASPD generally do not experience shame or guilt in the same way as others. They are more likely to be indifferent or dismissive about the consequences of their actions.

Choice A Reason: Insert a nasogastric tube

This choice is incorrect. Inserting a nasogastric tube is not the highest priority intervention for a client who has just received naloxone. While it may be necessary in some cases for other reasons, the immediate concern after naloxone administration is to ensure the client’s airway is open and they are breathing adequately. Naloxone reverses opioid effects, which can cause respiratory depression, so monitoring the airway and vital signs is crucial.

Choice B Reason: Monitor airway and vital signs

This choice is correct. The highest priority after administering naloxone is to monitor the client’s airway and vital signs. Naloxone can rapidly reverse opioid-induced respiratory depression, but its effects may wear off before the opioids are completely metabolized, leading to a risk of re-sedation and respiratory depression. Continuous monitoring ensures that any changes in the client’s condition are detected and managed promptly.

Choice C Reason: Insert an indwelling urinary catheter or monitor output

This choice is incorrect. While monitoring urine output can be important in assessing overall kidney function and fluid balance, it is not the highest priority immediately after naloxone administration. The primary concern is the client’s respiratory status and ensuring they maintain an open airway and adequate ventilation.

Choice D Reason: Anticipate and treat hyperpyrexia with cooling measures

This choice is incorrect. Hyperpyrexia (extremely high fever) is not a common immediate concern following naloxone administration. The primary focus should be on the client’s respiratory status and vital signs. Treating hyperpyrexia would be important if it were present, but it is not typically associated with naloxone administration.