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A nurse is developing a plan of care for a client who has borderline personality disorder and exhibits manipulative behavior. Which of the following interventions should the nurse include?
- A. Encourage flexibility with unit rules
- B. Implement consistent limit-setting
- C. Allow the client to negotiate consequences
- D. Avoid addressing manipulative behavior
Correct Answer: B
Rationale: The correct answer is B: Implement consistent limit-setting. For clients with borderline personality disorder and manipulative behavior, consistent limit-setting helps establish boundaries and promote a sense of security. By enforcing clear and consistent rules, the nurse can prevent manipulation and maintain a therapeutic environment. Encouraging flexibility with unit rules (choice A) may enable manipulation and disrupt the treatment process. Allowing the client to negotiate consequences (choice C) can reinforce manipulative behaviors. Avoiding addressing manipulative behavior (choice D) can lead to escalation and reinforcement of maladaptive behaviors.
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A nurse in an inpatient mental health facility is planning care for a client who has schizophrenia and is experiencing delusions. Which of the following interventions should the nurse include?
- A. Encourage the client to focus on reality-based topics
- B. Agree with the client’s delusional beliefs
- C. Discuss the delusions in detail
- D. Provide frequent reassurance about safety
Correct Answer: A
Rationale: The correct answer is A: Encourage the client to focus on reality-based topics. This intervention is appropriate because it helps the client ground themselves in reality and potentially reduce the intensity of their delusions. By redirecting the client's focus to reality-based topics, the nurse can help them challenge and eventually overcome their delusions. Choices B, C, and D are incorrect. Agreeing with delusional beliefs can reinforce them, discussing delusions in detail may exacerbate them, and providing frequent reassurance about safety may not address the underlying issue of delusions.
A nurse is providing teaching to the caregiver of a client who has schizophrenia. Which of the following statements by the caregiver indicates an understanding of the teaching?
- A. I should reinforce reality when my loved one is experiencing delusions.'
- B. I should discourage my loved one from expressing feelings.'
- C. I should avoid talking to my loved one about his hallucinations.'
- D. I should encourage my loved one to isolate when symptoms occur.'
Correct Answer: A
Rationale: The correct answer is A: "I should reinforce reality when my loved one is experiencing delusions." This statement indicates an understanding of the teaching because it aligns with the therapeutic approach of reality orientation, which helps the client differentiate between reality and delusions. By reinforcing reality, the caregiver can help the client manage their symptoms effectively.
Choices B, C, and D are incorrect because they promote behaviors that are not beneficial for a client with schizophrenia. Discouraging the expression of feelings (B) can lead to emotional suppression. Avoiding discussion about hallucinations (C) may prevent the caregiver from understanding the client's experiences. Encouraging isolation (D) can worsen symptoms and hinder social interaction, which is important for recovery.
A nurse is developing a behavioral contract with a client who has antisocial personality disorder. Which of the following client goals should the nurse include in the contract?
- A. Use projection during group therapy
- B. Increase self-esteem
- C. Use bargaining skills for behavioral consequences
- D. Decrease the number of verbal outbursts
Correct Answer: D
Rationale: The correct answer is D: Decrease the number of verbal outbursts. For a client with antisocial personality disorder, managing impulsivity and aggression is crucial. Decreasing verbal outbursts helps improve social interactions and relationships. Using projection (A) can exacerbate manipulative behavior. Increasing self-esteem (B) may not address the core issues of the disorder. Using bargaining skills (C) might reinforce manipulative tendencies rather than promoting genuine change in behavior.
A nurse is assessing a client who has alcohol use disorder and is experiencing withdrawal. Which of the following findings should the nurse expect?
- A. Hypotension
- B. Visual hallucinations
- C. Hyperactivity
- D. Increased appetite
Correct Answer: B
Rationale: The correct answer is B: Visual hallucinations. During alcohol withdrawal, the client may experience hallucinations, particularly visual ones, due to the impact of alcohol on the brain. This is known as alcohol hallucinosis. Hypotension (choice A) is not typically associated with alcohol withdrawal; in fact, hypertension is more common. Hyperactivity (choice C) is not a common symptom of alcohol withdrawal, as clients tend to be more agitated or restless. Increased appetite (choice D) is also not a typical finding during alcohol withdrawal, as many clients experience decreased appetite. Visual hallucinations are a key symptom to monitor for during alcohol withdrawal due to their potential to be distressing and require immediate intervention.
A nurse is planning care for a client who has experienced intimate partner abuse. The nurse should identify which of the following outcomes as the priority?
- A. The client joins a support group
- B. The client identifies techniques to reduce stress
- C. The client develops a safety plan
- D. The client identifies support systems
Correct Answer: C
Rationale: The correct answer is C: The client develops a safety plan. This is the priority outcome because it addresses the immediate safety of the client who is experiencing intimate partner abuse. A safety plan helps the client to identify strategies to protect themselves and seek help in times of danger. Joining a support group (A), identifying stress reduction techniques (B), and identifying support systems (D) are important steps in the client's overall recovery process but addressing safety concerns is crucial to prevent further harm. It is important to prioritize safety before addressing other aspects of the client's well-being.