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

Answer and Explanation

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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Correct Answer is A

Explanation

A. By using a screening tool such as the CAGE questionnaire: This is the correct answer. The CAGE questionnaire is a widely used tool for screening alcohol use disorders. It consists of four questions that assess whether the individual has concerns or issues related to their alcohol consumption. A positive result may indicate a need for further assessment and intervention.

B. By asking directly if the client has ever had a problem with alcohol: While direct questioning is important, using a structured screening tool provides a more standardized and objective approach. The CAGE questionnaire offers specific questions that help identify potential issues with alcohol use.

C. By holistically assessing the client using the CINA scale: The CINA scale (Checklist of Nonverbal Indicators of Affect) is primarily used to assess nonverbal behaviors related to affect. While it may be useful in certain contexts, it is not specifically designed for assessing alcohol use disorders.

D. By referring the client for physician evaluation: While physician evaluation may be necessary for a comprehensive assessment, using a screening tool such as the CAGE questionnaire is an appropriate initial step. The results of the screening tool can guide further assessment and appropriate referrals.

A. Researchers have been unable to demonstrate a link between nature (biology and genetics) and nurture (environment) B. Medications are one way to address chemical imbalances. Environmental and interpersonal factors can also have an impact on biological factors C. Because biological tactors are the sole cause of depression, medications will improve your mood D. Environmental factors have been shown to exert the most influence in the development of depression

Correct Answer is B

Explanation

A. Researchers have been unable to demonstrate a link between nature (biology and genetics) and nurture (environment): This statement is inaccurate. There is substantial evidence supporting the interaction between nature (biology and genetics) and nurture (environment) in the development of mental health conditions, including depression.

B. Medications are one way to address chemical imbalances. Environmental and interpersonal factors can also have an impact on biological factors: This is the correct answer. It acknowledges the role of medications in addressing chemical imbalances but also emphasizes the importance of environmental and interpersonal factors in influencing biological factors. This response aligns with a biopsychosocial model of understanding mental health.

C. Because biological factors are the sole cause of depression, medications will improve your mood: This statement oversimplifies the complex etiology of depression. Depression is a multifactorial condition influenced by biological, psychological, and environmental factors. Medications may be part of the treatment, but they are not the sole solution.

D. Environmental factors have been shown to exert the most influence in the development of depression: This statement is also incorrect. Depression is influenced by a combination of biological, psychological, and environmental factors. No single factor is solely responsible for the development of depression.

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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?

Nursing Test Bank

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