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A nurse is assessing a client who has histrionic personality disorder. Which of the following findings should the nurse expect?
- A. Lack of remorse
- B. Attention seeking
- C. Splitting of staff
- D. Identity disturbance
Correct Answer: B
Rationale: The correct answer is B: Attention seeking. In histrionic personality disorder, individuals often seek attention by being overly dramatic, seductive, or provocative. This behavior is a key characteristic of the disorder. Lack of remorse (A) is more indicative of antisocial personality disorder. Splitting of staff (C) is more commonly associated with borderline personality disorder. Identity disturbance (D) is a feature of borderline personality disorder as well. In summary, attention seeking behavior is a hallmark trait of histrionic personality disorder, making choice B the correct answer in this scenario.
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A nurse is planning care for a client with acute delirium. Which of the following instructions should the nurse include in the plan?
- A. Reinforce the clients orientation with the calendar
- B. Refute the clients perception of visual hallucinations
- C. Teach the client assertive techniques
- D. Assign the client to a different caregiver each shift
Correct Answer: A
Rationale: The correct answer is A: Reinforce the client's orientation with the calendar. This is because in acute delirium, the client may experience confusion and disorientation. Using a calendar can help provide structure and aid in orientation. Choice B is incorrect as refuting hallucinations may worsen the client's agitation. Choice C is incorrect as assertive techniques are not typically used in managing acute delirium. Choice D is incorrect as consistency in caregivers is important for continuity of care in delirium management.
A nurse is caring for a client who exhibits excessive compliance, passivity, and self-denial. The nurse should recognize that these findings are associated with which of the following personality disorders?
- A. Dependent
- B. Paranoid
- C. Borderline
- D. Histrionic
Correct Answer: C
Rationale: The correct answer is C: Borderline. Excessive compliance, passivity, and self-denial are characteristic traits of individuals with Borderline Personality Disorder. They often struggle with identity, exhibit intense emotions, and have unstable relationships. Choice A, Dependent Personality Disorder, is characterized by a pervasive psychological dependence on others. Choice B, Paranoid Personality Disorder, involves distrust and suspiciousness. Choice D, Histrionic Personality Disorder, is characterized by attention-seeking behavior and emotional overreaction. Choices E, F, and G are irrelevant. In this scenario, the client's behaviors align most closely with the features of Borderline Personality Disorder.
A nurse in an inpatient mental health facility is assessing a client who has schizophrenia and is taking haloperidol. Which of the following clinical findings is the nurse’s priority?
- A. High fever
- B. Insomnia
- C. Urinary hesitancy
- D. Headache
Correct Answer: A
Rationale: The correct answer is A: High fever. The priority finding is high fever because it could indicate a potentially serious adverse reaction called neuroleptic malignant syndrome (NMS) associated with haloperidol use. NMS is a life-threatening condition characterized by fever, altered mental status, muscle rigidity, and autonomic dysfunction. Prompt recognition and treatment of NMS are crucial to prevent complications. Insomnia (B), urinary hesitancy (C), and headache (D) are common side effects of haloperidol but are not as urgent as high fever, which could signify a medical emergency.
A nurse is assisting with obtaining informed consent from a client who has been declared legally incompetent. Which of the following actions should the nurse take?
- A. Contact the facility social worker to obtain the consent
- B. Explain implied consent to the client’s family
- C. Request that the client’s guardian sign the consent
- D. Ask the charge nurse to obtain informed consent
Correct Answer: C
Rationale: The correct answer is C: Request that the client’s guardian sign the consent. This is appropriate because a legally incompetent individual requires a guardian to make decisions on their behalf. This ensures that the client's best interests are protected and that decisions are made by someone legally authorized to do so. Choice A is incorrect because social workers are not authorized to provide consent for legally incompetent individuals. Choice B is incorrect as implied consent is not applicable in this scenario. Choice D is incorrect as the charge nurse does not have the legal authority to obtain informed consent for a legally incompetent client.
A nurse is reviewing laboratory findings for a client who is taking valproic acid. Which of the following results should the nurse report to the provider?
- A. Platelets 250,000/mm³
- B. AST 45 units/L
- C. WBC 9,000/mm³
- D. ALT 65 units/L
Correct Answer: D
Rationale: The correct answer is D: ALT 65 units/L. Elevated ALT levels indicate potential liver damage, a known side effect of valproic acid. The nurse should report this to the provider for further evaluation. Platelets, AST, and WBC levels are within normal ranges, so they do not require immediate reporting. In summary, the correct answer is focused on a potential serious side effect related to the medication, while the other choices are not directly linked to valproic acid or indicate normal laboratory values.