A nurse is creating a plan of care for a client who has antisocial personality disorder. Which of the following interventions should the nurse include?

Appoint the client to be the leader during group therapy.

Monitor the client's interactions with other clients.

Offer the client two warnings before implementing consequences.

Assign the client to a room near the activity area.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Appointing the client as a leader may not be appropriate, as individuals with antisocial personality disorder may misuse their position of authority.

Choice B rationale:

Clients with antisocial personality disorder often struggle with interpersonal relationships, may be manipulative, and may engage in behaviors that violate the rights of others. Monitoring the client's interactions with other clients helps ensure a safe and therapeutic environment while preventing harm to others.

Choice C rationale:

Offering warnings before consequences might not be effective with clients who have antisocial personality disorder, as they may disregard rules and consequences.

Choice D rationale:

Assigning a room near the activity area does not necessarily address the need to monitor the client's interactions with others.

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

Explanation

Choice A rationale:

Agitation is a common manifestation of delirium, as the client experiences a disturbance in attention, awareness, and cognition. The client may become restless, irritable, or aggressive due to the altered mental state.

Choice B rationale:

Slow, flat speech is not a manifestation of delirium, but rather a sign of depression or dementia. Clients with delirium may have rapid, incoherent, or slurred speech, depending on the cause and severity of the condition.

Choice C rationale:

Visual hallucinations are another manifestation of delirium, as the client may perceive things that are not there or misinterpret sensory stimuli. The client may also have auditory or tactile hallucinations, which can contribute to the agitation and confusion.

Choice D rationale:

Confusion is a hallmark manifestation of delirium, as the client has difficulty with orientation, memory, and reasoning. The client may not recognize familiar people or places, or may have fluctuating levels of consciousness. The confusion may worsen at night or in low-light settings, which is known as sundowning syndrome.

Choice E rationale:

Rapid mood swings are also a manifestation of delirium, as the client may exhibit emotional lability, anxiety, depression, fear, or anger. The mood changes may be unpredictable and inappropriate to the situation.

A. Check cervical dilation every 2 hr. B. Initiate an IV with an 18-gauge catheter. C. Monitor FHR hourly. D. Obtain vital signs every 4 hr.

Correct Answer is B

Explanation

Choice A rationale:

Frequent cervical examinations may increase the risk of introducing infection or causing additional bleeding. Cervical examinations are not a priority in managing placental abruption.

Choice B rationale:

Placental abruption can lead to significant blood loss, and the client may require intravenous fluids and blood products to maintain hemodynamic stability. Initiating an IV with an 18-gauge catheter allows for rapid administration of fluids and blood products if needed.

Choice C rationale:

Monitoring fetal heart rate hourly is important, but addressing the mother's hemodynamic stability with IV fluids takes priority.

Choice D rationale:

Vital signs should be obtained more frequently than every 4 hours due to the risk of ongoing blood loss.

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A nurse is creating a plan of care for a client who has antisocial personality disorder. Which of the following interventions should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has delirium. Which of the following manifestations should the nurse expect? (Select all that apply.)

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

Explanation

A nurse is planning care for a client who is experiencing moderate vaginal bleeding due to a placental abruption. Which of the following interventions should the nurse include in the plan?

Correct Answer is B

Explanation

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