A nurse is caring for a client who is unable to make any decisions for themselves and needs constant reassurance. The nurse should identify that these are manifestations of which of the following personality disorders?

Avoidant personality disorder

Borderline personality disorder

Dependent personality disorder

Schizoid personality disorder

Answer and Explanation

The Correct Answer is C

Choice A reason : Avoidant personality disorder is characterized by a pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation. Individuals with this disorder may avoid work activities or decline job offers due to fears of criticism or rejection. However, they do not typically exhibit a need for constant reassurance or an inability to make decisions, which are more indicative of dependent personality disorder⁵⁶.

Choice B reason : Borderline personality disorder involves a pattern of instability in interpersonal relationships, self-image, and affects, and marked impulsivity. While individuals with borderline personality disorder may exhibit dependency traits, they are more likely to engage in frantic efforts to avoid real or imagined abandonment and may have a pattern of unstable and intense interpersonal relationships⁷⁸.

Choice C reason : Dependent personality disorder is characterized by a pervasive and excessive need to be taken care of, leading to submissive and clinging behavior and fears of separation. Individuals with this disorder often require excessive advice and reassurance from others to make everyday decisions and may feel helpless when alone due to exaggerated fears of being unable to care for themselves. The need for constant reassurance and inability to make decisions align with the symptoms of dependent personality disorder¹²³⁴.

Choice D reason : Schizoid personality disorder is characterized by a lack of interest in social relationships, a tendency toward a solitary lifestyle, secretiveness, emotional coldness, detachment, and apathy. Individuals with schizoid personality disorder prefer to be alone and do not seek out social interactions or relationships. They do not typically display the need for reassurance or the inability to make decisions, as seen in dependent personality disorder¹²¹³¹⁴.

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Correct Answer is ["A","B","C","D"]

Explanation

Choice A reason : Pupillary changes, such as unequal pupil sizes or a sluggish reaction to light, can be a sign of increased ICP. The cranial nerves that control the pupils may be compressed due to the swelling of the brain, leading to these changes¹.

Choice B reason : Disorientation, including confusion and changes in alertness, can occur with increased ICP as the pressure affects the brain's ability to process information and maintain consciousness².

Choice C reason : Headache is a common symptom of increased ICP. It can be severe and persistent due to the pressure exerted on the meninges and blood vessels within the brain³.

Choice D reason : Slurred speech may result from increased ICP if the areas of the brain responsible for speech and muscle control are affected by the pressure².

Choice E reason : Neck pain and stiffness, particularly when trying to flex the neck forward, can be indicative of meningeal irritation, which can be associated with increased ICP⁴.

A. "It usually takes heparin at least 2 to 3 days to reach a therapeutic blood level." B. "A pharmacist is the person to answer that question." C. "Heparin does not dissolve clots. It stops new clots from forming." D. "The oral medication you will take after this IV will dissolve the clot."

Correct Answer is C

Explanation

Choice A reason : This statement is misleading. While heparin does need to reach a therapeutic level to be effective, it does not directly dissolve existing clots. Heparin's primary action is to prevent the formation of new clots and the extension of existing clots by inhibiting certain factors in the coagulation cascade.

Choice B reason : While a pharmacist can provide detailed information about medications, it is the nurse's responsibility to educate and inform the client about the effects of their treatment. Therefore, this response would not be appropriate.

Choice C reason : This is the most accurate response. Heparin works by inhibiting the formation of fibrin, which is essential for clot formation. It does not have the ability to dissolve existing clots but can prevent new ones from forming and existing ones from getting larger.

Choice D reason : Oral medications such as warfarin or direct oral anticoagulants (DOACs) may be used after heparin to maintain anticoagulation; however, they also do not dissolve clots. The body's natural fibrinolytic system is responsible for breaking down clots over time.

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A nurse is caring for a client who is unable to make any decisions for themselves and needs constant reassurance. The nurse should identify that these are manifestations of which of the following personality disorders?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is monitoring a client who has a leaking cerebral aneurysm. Which of the following manifestations should indicate to the nurse that the client is experiencing an increase in intracranial pressure (ICP)? (Select all that apply.)

Correct Answer is ["A","B","C","D"]

Explanation

A nurse is caring for a client who has thrombophlebitis and is receiving heparin by continuous IV infusion. The client asks the nurse how long it will take for the heparin to dissolve the clot. Which of the following responses should the nurse give?

Correct Answer is C

Explanation

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