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A nurse is working with a group of clients during group therapy. For which of the following client disorders will setting limits serve as an appropriate behavioral management technique?
- A. Delirium
- B. Depression
- C. Antisocial personality disorder
- D. Generalized anxiety disorder
Correct Answer: C
Rationale: Setting limits is an essential behavioral management technique for clients with antisocial personality disorder. Individuals with this disorder often exhibit manipulative, deceitful, and aggressive behaviors. Clear and consistent limits help establish boundaries and prevent the exploitation of others. This approach promotes accountability and helps manage inappropriate behaviors in a therapeutic setting.
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A charge nurse is reinforcing teaching with a newly licensed nurse about the clinical manifestations of dependent personality disorder. Which of the following manifestations should the nurse include in the teaching?
- A. Unable to make simple decisions
- B. Enjoys spending time alone
- C. Exhibits extreme perfectionism
- D. Displays confrontational behavior
Correct Answer: A
Rationale: Individuals with dependent personality disorder often struggle with making simple decisions without excessive advice and reassurance from others. They have a strong need for others to take responsibility for major areas of their lives and can feel helpless when alone. This indecisiveness is a hallmark of the disorder and stems from their lack of self-confidence and reliance on others for guidance and support.
A charge nurse overhears a staff nurse talking to a nurse from another unit in the hallway. The staff nurse says
- A. I heard that Mr. Smith was admitted for a suicide attempt. Which of the following responses should the charge nurse make?
- B. I will be informing the provider about this conversation.
- C. You should continue this conversation in a private place.
- D. It is an invasion of privacy to discuss that information.
- E. If you are going to talk about a client in public, do not use their name.
Correct Answer: C
Rationale: This response directly addresses the issue of discussing private patient information and reinforces the importance of maintaining confidentiality. By stating that it is an invasion of privacy to discuss the information, the charge nurse makes it clear that such conversations are inappropriate and should not occur.
A nurse is receiving report on four clients at the beginning of the shift. Which of the following clients should the nurse check first?
- A. A client who is hearing command hallucinations.
- B. A client who is verbalizing ideas of reference.
- C. A client who is using neologisms.
- D. A client who is demonstrating clang associations.
Correct Answer: A
Rationale: A client who is hearing command hallucinations should be prioritized first because command hallucinations can be particularly dangerous. These hallucinations can involve voices instructing the client to harm themselves or others. Immediate assessment and intervention are crucial to ensure the client's safety and to prevent potential harm.
A nurse is reinforcing teaching with a client who has generalized anxiety disorder and a new prescription for buspirone. Which of the following information should the nurse include?
- A. This medication is known to cause dependence.
- B. Avoid consuming large amounts of leafy, green vegetables while taking this medication.
- C. It can take several weeks before you notice an effect from the medication.
- D. If a dose is missed, you can take the missed dose along with the next scheduled dose.
Correct Answer: C
Rationale: Buspirone typically takes several weeks to achieve its full therapeutic effect. Clients should be advised to continue taking the medication as prescribed and not to expect immediate relief of anxiety symptoms. This information helps set realistic expectations and encourages adherence to the treatment plan.
A nurse is collecting data from a client who experienced physical abuse as a child. Which of the following findings should the nurse identify as a risk factor for the client to become a perpetrator of child abuse?
- A. Low tolerance for frustration.
- B. Involved in community activities.
- C. Submissive personality.
- D. Absence of impulsive behaviors.
Correct Answer: A
Rationale: Low tolerance for frustration is a significant risk factor for becoming a perpetrator of child abuse. Individuals who have difficulty managing their frustration may be more likely to react impulsively and aggressively when faced with challenging situations. This inability to cope with frustration can lead to abusive behaviors, especially if the individual has not developed healthy coping mechanisms.