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","E","F"]
Explanation
Choice A rationale:
Pedal pulses are a measure of peripheral circulation. A 2+ rating is considered normal, indicating a brisk, expected response. There’s no change in the client’s pedal pulses from Day 1 to Day 5, so this doesn’t require immediate follow-up.
Choice B rationale:
Oxygen saturation is not mentioned in the Nurses’ Notes, so we cannot provide a rationale for this choice.
Choice C rationale:
Breath sounds are an important indicator of respiratory health. The client’s breath sounds are clear and present throughout on both Day 1 and Day 5, which is normal and doesn’t require immediate follow-up.
Choice D rationale:
Respiratory rate is not mentioned in the Nurses’ Notes, but any significant change in respiratory rate could indicate a problem such as infection or pain, and would require immediate follow-up.
Choice E rationale:
The abdominal dressing shows a large amount of serosanguinous drainage on Day 5, compared to a small amount on Day 1. This could indicate a complication such as infection or dehiscence (separation of the wound), especially since the client reported feeling something “popped” at the incision site after coughing. This requires immediate follow-up.
Choice F rationale:
Heart rate is not mentioned in the Nurses’ Notes, but any significant change in heart rate could indicate a systemic response to factors such as pain or infection, and would require immediate follow-up. In summary, while pedal pulses and breath sounds remain normal, the change in the abdominal dressing and potential changes in respiratory rate and heart rate (though not documented here) should be addressed immediately to ensure the client’s health and recovery.
Correct Answer is A
Explanation
The correct answer is: a. Remove bibs when the infant is going to sleep.
Choice A reason: Removing bibs when an infant is going to sleep is a critical safety measure to prevent suffocation and strangulation risks. Infants should have a sleep environment free of any loose objects that could cover their face and interfere with breathing. The American Academy of Pediatrics recommends keeping the crib clear of items like bibs, pillows, blankets, and toys to reduce the risk of Sudden Infant Death Syndrome (SIDS) and other sleep-related infant deaths.
Choice B reason: Using a highchair for feedings is not recommended for a 3-month-old infant because they typically cannot sit up unsupported at this age. Highchairs are generally used when an infant can sit up well without support and has good head control, usually around 6 months old. Until then, infants should be held or placed in an appropriate reclined feeding position.
Choice C reason: A soft crib mattress is not advisable for infants. A firm mattress is essential to provide a safe sleep surface. Soft mattresses and other soft surfaces increase the risk of SIDS and suffocation because they can create pockets that may cause an infant’s face to sink in and restrict breathing.
Choice D reason: Placing pillows in the crib, even one small pillow, is unsafe for infants. Pillows can pose a suffocation hazard and increase the risk of SIDS. The crib should be kept bare, with only a firm mattress and a fitted sheet, to ensure a safe sleep environment for the infant.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.