A nurse is caring for a client who has antisocial personality disorder who requests to smoke outside of scheduled smoke breaks.
Which of the following is an appropriate response by the nurse?
"Let me check with the charge nurse to see if your smoke breaks can be adjusted.”
"Why do you feel we should allow you extra smoke breaks?”
"I can give you an extra smoke break if you agree to participate in group therapy.”
"The smoking times on the unit are after each meal.”
The Correct Answer is A
Choice A rationale:
The appropriate response by the nurse in this situation is to consider the client's request and check with the charge nurse to see if it's possible to adjust the smoke breaks. This response demonstrates a willingness to listen to the client's request and explore the possibility of accommodating their needs within the unit's policies and routines. It does not immediately grant the request but shows respect for the client's concerns and attempts to find a compromise.
Choice B rationale:
Asking the client why they feel extra smoke breaks should be allowed is not the best response. It may come across as confrontational and defensive, which can escalate the situation. Clients with antisocial personality disorder may have difficulty adhering to rules, so it's essential to approach their requests with a collaborative and problem-solving attitude.
Choice C rationale:
Offering an extra smoke break in exchange for participation in group therapy is not an appropriate response. It can be seen as manipulating the client or using rewards to control their behavior. It's essential to maintain clear boundaries and not use rewards or punishments as a means of managing clients with personality disorders.
Choice D rationale:
Telling the client the smoking times on the unit are after each meal is not an appropriate response either. It doesn't address the client's request and simply restates the unit's policy. It's important to engage in a more therapeutic and client-centered approach when responding to requests from individuals with personality disorders.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Hyperreflexia is not a common manifestation of Stevens-Johnson syndrome (SJS) SJS typically presents with skin and mucous membrane involvement, such as a skin rash, blistering, and mucosal lesions. Hyperreflexia is more commonly associated with neurological conditions, and it is not a typical symptom of SJS.
Choice B rationale:
Tinnitus with ear pain is not a characteristic manifestation of Stevens-Johnson syndrome (SJS) SJS primarily affects the skin and mucous membranes and does not typically involve the ears or auditory system. Tinnitus with ear pain could be related to other ear or auditory issues but is not associated with SJS.
Choice C rationale:
Diplopia (double vision) is not a typical manifestation of Stevens-Johnson syndrome (SJS) SJS primarily presents with skin and mucous membrane symptoms, including a rash, blisters, and mucosal lesions. Diplopia is more commonly associated with eye conditions or neurological disorders and is not a direct symptom of SJS.
Choice D rationale:
Skin rash with fever is a crucial manifestation to monitor and report in a client taking allopurinol because it can be indicative of Stevens-Johnson syndrome (SJS) Allopurinol is known to be associated with severe skin reactions like SJS, which can initially present as a skin rash with fever. Early recognition and reporting of this symptom are essential to prevent further complications. SJS is a medical emergency that requires immediate intervention.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
Explanation
The correct answer is choice B and C.
Choice A rationale:
Cervical insufficiency is a condition where the cervix begins to shorten and open too early during pregnancy, leading to premature birth or loss of an otherwise healthy pregnancy. However, the client’s symptoms do not indicate cervical insufficiency. There are no reports of lower abdominal pressure, mild pelvic cramps, or a change in vaginal discharge, which are common symptoms of cervical insufficiency.
Choice B rationale:
The client’s severe headache unrelieved by acetaminophen, +3 pitting edema in bilateral lower extremities, and hyperactive reflexes (patellar reflex 4+) are indicative of severe preeclampsia. One of the complications of severe preeclampsia is seizures, also known as eclampsia. Therefore, the client is at risk for developing seizures.
Choice C rationale:
Placental abruption is a serious pregnancy complication in which the placenta detaches from the uterus prematurely. The client’s report of decreased fetal movement could be a sign of placental abruption. In addition, severe preeclampsia can increase the risk of placental abruption. Therefore, the client is at risk for developing placental abruption.
Choice D rationale:
Heart failure occurs when the heart can’t pump enough blood to meet the body’s needs. While preeclampsia can eventually affect many organ systems including the cardiovascular system, there are no immediate signs of heart failure in the client’s symptoms.
Choice E rationale:
Hypoglycemia refers to low blood sugar levels. The client’s symptoms do not suggest hypoglycemia. Symptoms of hypoglycemia typically include confusion, dizziness, feeling shaky, hunger, headaches, irritability, pounding heart or irregular heartbeat, sweating, trembling or tremors, and weakness. In conclusion, based on the client’s symptoms and clinical presentation, she is at greatest risk for developing seizures (Choice B) and placental abruption (Choice C) due to severe preeclampsia.
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