During an assessment interview, a client diagnosed with antisocial personality disorder spits, curses, and refuses to answer questions. Which is the most appropriate nursing statement to address this behavior?
I understand that you are angry, but this behavior will not be tolerated
You are very disrespectful. You need to learn to control yourself.
What behaviors could you modify to improve this situation?
What anti-personality disorder medications have helped you in the past
The Correct Answer is A
A. "I understand that you are angry, but this behavior will not be tolerated": This response sets a clear boundary regarding unacceptable behavior while acknowledging the client's emotional state. It communicates to the client that their actions are not acceptable, but it does so in a firm yet empathetic manner. This statement also maintains professionalism and ensures a safe and respectful environment for both the client and the nurse.
B. "You are very disrespectful. You need to learn to control yourself": This statement is confrontational and may escalate the client's anger or resistance. It focuses on blaming the client rather than exploring potential modifications to improve the situation.
C. "What behaviors could you modify to improve this situation?": may not be as effective in this context because it places the responsibility solely on the client to modify their behavior without directly addressing the inappropriate actions exhibited. Additionally, individuals with antisocial personality disorder may have difficulty recognizing the impact of their behavior on others or may be resistant to changing their actions without external intervention or consequences.
D. "What anti-personality disorder medications have helped you in the past?": Antisocial personality disorder is not typically treated with specific medications, and individuals with this disorder may not seek or comply with medication interventions. Asking about medications may not be relevant or helpful in addressing the immediate behavioral issues.
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Related Questions
Correct Answer is C
Explanation
A. Teaching clients about their illness: This function is within the scope of practice for both registered nurses and advanced practice psychiatric nurses. Registered nurses often provide education to clients about their illnesses, medications, and overall care.
B. Maintaining safety on the milieu: Both registered nurses and advanced practice psychiatric nurses are responsible for maintaining safety on the milieu. This includes monitoring the environment, assessing potential risks, and intervening to ensure the safety of clients and staff.
C. Prescribing medications: This function is exclusive to advanced practice psychiatric nurses, such as psychiatric nurse practitioners. Registered nurses do not have the authority to prescribe medications. Advanced practice psychiatric nurses receive additional education and training that allows them to prescribe medications as part of their role.
D. Administering medications: Registered nurses, including those specializing in psychiatric nursing, are authorized to administer medications. This is a common nursing function and does not require advanced practice authorization.
Correct Answer is D
Explanation
A. Implement the client's behavioral modification plan:
While addressing the client's behavioral modification plan is important, it may not be the immediate priority when the client has self-inflicted cuts. Ensuring physical safety and assessing the extent of the injury take precedence.
B. Document the size and location of the cuts:
Documentation is important, but it is not the first action to be taken. The immediate concern is to assess the physical condition of the cuts and address any potential risks.
C. Administer a tetanus antitoxin:
Administering a tetanus antitoxin may be necessary depending on the nature and depth of the cuts. However, it is not the first action. First, a thorough inspection of the cuts is needed to determine the appropriate course of action.
D. Inspect the cuts for debris:
This is the most appropriate first action. Inspecting the cuts for debris helps determine the severity of the wounds and whether there is a risk of infection. It also allows the nurse to assess the need for further medical intervention.
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