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A client has been diagnosed with histrionic personality disorder. Which of the following behaviors should the nurse expect?
- A. Attention-seeking behavior
- B. Dramatic expressions of emotion
- C. Seductive behavior
- D. Dependency on others
Correct Answer: A
Rationale: Individuals with histrionic personality disorder often display attention-seeking behaviors as a way to draw focus and validation from others. This behavior may manifest as exaggerated emotions and dramatic expressions to maintain the spotlight. While seductive behavior and dependency on others are potential characteristics of histrionic personality disorder, attention-seeking behavior is the hallmark trait. Therefore, the correct answer is attention-seeking behavior (Choice A). Dramatic expressions of emotion (Choice B) can be a feature of histrionic personality disorder, but it is not as characteristic as attention-seeking behavior. Seductive behavior (Choice C) may also be present in individuals with histrionic personality disorder, but it is not the primary behavior to expect. Dependency on others (Choice D) is not a core feature of histrionic personality disorder, although individuals with this disorder may seek attention and validation from others.
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A client with schizophrenia is experiencing auditory hallucinations. Which intervention should the nurse implement first?
- A. Ask the client to describe the content of the hallucinations.
- B. Instruct the client to ignore the hallucinations.
- C. Administer prescribed antipsychotic medication.
- D. Engage the client in reality-based activities.
Correct Answer: A
Rationale: The initial intervention for a client experiencing auditory hallucinations, especially in schizophrenia, is to assess the content of the hallucinations. By asking the client to describe the hallucinations, the nurse can determine if they are command hallucinations that might pose a risk. This assessment is crucial in guiding further appropriate interventions to ensure the client's safety and well-being. Instructing the client to ignore the hallucinations (Choice B) may not be effective, as the hallucinations are real to the client. Administering antipsychotic medication (Choice C) may be necessary but should come after assessing the situation. Engaging the client in reality-based activities (Choice D) is important but not the first priority when dealing with auditory hallucinations.
During an intake assessment, a nurse asks both physiological and psychosocial questions. The client angrily responds, 'I'm here for my heart, not my head problems.' What is the nurse's best response?
- A. It's just a routine part of our assessment. All clients are asked these same questions.
- B. Why are you concerned about these types of questions?
- C. Psychological factors, like excessive stress, have been found to affect medical conditions.
- D. We can skip these questions, if you like. It isn't imperative that we complete this section.
Correct Answer: C
Rationale: The nurse should educate the client about the impact of psychological factors, such as excessive stress, on medical conditions. Understanding this connection is crucial in providing holistic care. It is essential to address both physiological and psychosocial aspects during the assessment to obtain a comprehensive understanding of the client's health status and needs. Choice A is incorrect as it doesn't address the importance of psychosocial aspects on medical conditions. Choice B is not the best response as it does not provide valuable information about the connection between psychological factors and medical conditions. Choice D is incorrect because skipping these questions could lead to missing crucial information that may impact the client's overall well-being and treatment plan.
A client has been prescribed lorazepam (Ativan) for the treatment of anxiety. Which of the following instructions should the nurse include?
- A. Take the medication with food to avoid stomach upset.
- B. Avoid driving until you know how the medication affects you.
- C. Take the medication on an empty stomach.
- D. Double the dose if you miss a dose.
Correct Answer: B
Rationale: The correct answer is B because lorazepam (Ativan) can cause dizziness and drowsiness, so the client should avoid driving until they know how the medication affects them. This instruction is crucial for ensuring the client's safety and preventing any potential accidents or harm. Choice A is incorrect because lorazepam does not necessarily need to be taken with food. Choice C is incorrect as it contradicts the usual recommendation of taking lorazepam with or without food. Choice D is incorrect and dangerous advice as doubling the dose of lorazepam can lead to overdose and serious complications.
A school nurse is assessing a female high school student who is overly concerned about her appearance. The client's mother states, 'That's not something to be stressed about!' Which is the most appropriate nursing response?
- A. Teenagers! They don't know a thing about real stress.
- B. Stress occurs only when there is a loss.
- C. When you are in poor physical condition, you can't experience psychological well-being.
- D. Stress can be psychological. A threat to self-esteem may result in high stress levels.
Correct Answer: D
Rationale: The most appropriate response is D: 'Stress can be psychological. A threat to self-esteem may result in high stress levels.' This response acknowledges the psychological aspect of stress and how a perceived threat to self-esteem can be just as stressful as a physiological change. Choices A, B, and C are incorrect because they do not address the client's concerns or provide a therapeutic response to the situation.
A client with bipolar disorder is experiencing a manic episode. Which of the following interventions should the nurse implement? Select one that does not apply.
- A. Provide a structured environment
- B. Encourage rest periods
- C. Limit setting on inappropriate behaviors
- D. Allow the client to engage in stimulating activities
Correct Answer: D
Rationale: During a manic episode, it is essential to provide a structured environment to help the client maintain stability. Encouraging rest periods is crucial as excessive activity during mania can lead to exhaustion. Setting limits on inappropriate behaviors helps ensure the client's safety and the safety of others. Allowing the client to engage in stimulating activities can exacerbate manic symptoms by further increasing their energy levels and impulsivity. This can lead to a worsening of the manic episode and potentially risky behaviors. Therefore, allowing the client to engage in stimulating activities is not an appropriate intervention during a manic episode.