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The mental health nurse is caring for a client with Cluster B personality disorder. The nurse would expect the client to exhibit which behaviors? Select all that apply.
- A. suspicious of others, magical thinking, eccentric behavior, paranoia, relationship deficits
- B. preoccupation with rules and details, hoarding, ritualistic behavior, extremely devoted to work
- C. easily bored, poor and shallow interpersonal relationships, enjoys being the center of attention
- D. impulsivity, unpredictable behavior, extreme mood shifts, easily angered, playing people against each other
- E. suspicious and untrusting of others, argumentative, controlling of others, thoughts of grandiosity
Correct Answer: C,D
Rationale: Cluster B personality disorders (e.g., histrionic, borderline) involve attention-seeking, shallow relationships, impulsivity, and mood instability. Options A and E describe Cluster A, and B describes Cluster C.
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The nurse is talking to a group of student nurses about content of thought in clients with schizophrenia. The nurse gives an example of a client stating that her new tooth filling allows her to communicate with the Secret Service and follow their directives. Which response correctly identifies this content of thought?
- A. somatic delusion
- B. delusion of grandeur
- C. delusion of persecution
- D. delusion of control or influence
Correct Answer: D
Rationale: A delusion of control or influence involves believing external forces or entities control one's thoughts or actions, as in the client's belief that a tooth filling enables communication with the Secret Service.
The nurse is caring for a client whose family brought him to the hospital because they were worried about his personal safety. Which of the following statements by the client during the admission assessment indicates the need for immediate intervention by the nurse?
- A. Things are so bad that sometimes I don't know what to do make them better.
- B. My family normally supports my goals and helps me when I have a difficult time.
- C. I wish that everyone would leave me alone and quit trying to give me advice all the time.
- D. I keep a gun in my nightstand and sometimes I fall asleep holding it, trying to decide if I should pull the trigger or not.
Correct Answer: D
Rationale: This statement indicates active suicidal ideation with a plan and means, requiring immediate intervention to ensure safety.
The nurse is developed a teaching plan for a client prescribed spironolactone. On which psychosocial side effect of the medication should the nurse base the teaching plan?
- A. Edema
- B. Hair loss
- C. Weight loss
- D. Decreased libido
Correct Answer: D
Rationale: The nurse should be aware of the fact that the client taking spironolactone, a potassium-sparing diuretic, may experience body image changes that result from a threatened sexual identity. These are related to decreased libido, gynecomastia in males, and hirsutism in females. Edema, weight loss, and hair loss are not specifically associated with the use of this medication.
The nurse is caring for a client with a diagnosis of terminal cancer of the throat. The family tells the nurse that they have spoken to the primary health care provider regarding taking their loved one home. The nurse plans to coordinate discharge planning. Which service would be most supportive to the client and the family?
- A. Hospice care
- B. The American Cancer Society
- C. The American Lung Association
- D. Local religious and social organizations
Correct Answer: A
Rationale: Hospice care provides an environment that emphasizes caring rather than curing; the emphasis is on palliative care. One of the major goals of hospice care is that clients be free of pain and other symptoms that do not allow them to maintain a quality life. An interdisciplinary approach is used. Although the remaining options may be helpful, they are not the most supportive of the options provided.
A postoperative client displays signs of anxiety when the nurse explains that the intravenous (IV) line will need to be discontinued as a result of an infiltration. Which appropriate statement should the nurse make to the client?
- A. This is usually a painless experience. It is nothing to worry about.'
- B. I'm sure it will be a real relief for you just as soon as I discontinue this IV for good.'
- C. Just relax and take a deep breath. This procedure will not take long, and it will be over soon.'
- D. I can see that you're anxious. Removal of the IV shouldn't be painful, but the IV will need to be restarted in another location.'
Correct Answer: D
Rationale: The correct option addresses the client's anxiety and honestly informs the client that the IV may need to be restarted. This option uses the therapeutic technique of giving information, and it also acknowledges the client's feelings. Although discontinuing an IV is a painless experience, it is not therapeutic to tell a client not to worry. Option 2 does not acknowledge the client's feelings, and it does not tell the client that an infiltrated IV may need to be restarted. Option 3 does not address the client's feelings.