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A nurse is collecting data for a health history from a client who has antisocial personality disorder. Which of the following clinical findings is associated with this disorder?
- A. Withdrawn behaviors.
- B. Blunted affect.
- C. Excessively anxious.
- D. Exploitive of others.
Correct Answer: D
Rationale: Exploitive of others is a key characteristic of antisocial personality disorder. Individuals often disregard others’ rights and manipulate them for personal gain, aligning with the disorder’s profile.
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A client who delivered a healthy newborn 4 weeks ago calls her provider's office and tells the nurse
- A. This baby constantly cries. My partner works all the time
- B. and I can't take any more.' Which of the following responses is the nurse’s priority?
- C. Have you discussed this with your partner.
- D. Do you have a friend who could help you.
- E. Tell me about your baby.
- F. Have you tried any soothing techniques for your baby.
Correct Answer: C
Rationale: Asking about the baby’s current condition immediately assesses safety and well-being, which is the nurse’s priority. This ensures potential risks, like postpartum depression or infant harm, are addressed first.
A nurse is reinforcing teaching with a client who started taking haloperidol decanoate 125 mg IM 1 month ago. Which of the following statements by the client should the nurse address?
- A. I check my blood pressure once a week.
- B. I chew sugar-free gum several times daily.
- C. I haven't had a drink of alcohol since I started taking these injections.
- D. I spend several hours a day outside gardening when it's sunny.
Correct Answer: D
Rationale: Spending several hours outside in the sun could increase the risk of photosensitivity, a side effect of haloperidol. The nurse should address this to educate the client on protective measures like sunscreen use.
A nurse is caring for a client who is receiving acute care for the treatment of a substance use disorder. With which of the following actions is the nurse demonstrating the ethical principle of veracity?
- A. Reinforcing information on the potential adverse effects of a medication with the client.
- B. Encouraging the client to attend a daily exercise program on the unit.
- C. Respecting the client's right to refuse to attend a group therapy session.
- D. Maintaining the client's confidentiality about a substance use disorder.
Correct Answer: A
Rationale: Reinforcing information on the potential adverse effects of a medication demonstrates veracity, the principle of truthfulness. It ensures the client is fully informed, supporting ethical care and decision-making.
A nurse is caring for a group of clients in a pediatric clinic. Which of the following clients is at highest risk for physical abuse?
- A. An adolescent who is preparing to leave home for college.
- B. A preschooler who is reluctant to share.
- C. A school-age child who wants to go away to summer camp.
- D. A toddler who has cystic fibrosis.
Correct Answer: D
Rationale: Toddlers with chronic illnesses like cystic fibrosis may be at higher risk for physical abuse due to the increased stress and demands on caregivers. This vulnerability elevates their risk compared to typically developing peers.
A nurse is collecting data from an older adult client who was admitted with heart failure. The nurse should report which of the following findings to the provider as an indication of delirium?
- A. Fluctuating level of orientation.
- B. Consistent state of depression.
- C. Demonstrates obsessive behaviors.
- D. Short-term memory loss.
Correct Answer: A
Rationale: A fluctuating level of orientation is a hallmark sign of delirium. Delirium is characterized by an acute and fluctuating course of altered mental status, including changes in attention and cognition, distinguishing it from depression or dementia.