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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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A 12-year-old client is seen in the health care clinic. During the assessment, which finding would suggest to the nurse that the client is experiencing a disruption in the development of self-concept?
- A. The child has many friends.
- B. The child has a part-time babysitting job.
- C. The child has an intimate relationship with a significant other.
- D. The child enjoys playing chess and mastering new skills with this game.
Correct Answer: C
Rationale: The formation of an intimate relationship would not be expected until young adulthood. Friends are important and appropriate for members of this age group. A sense of industry is appropriate for this age group, and it may be exhibited by the child having a part-time job. The increase in self-esteem associated with skill mastery is an important part of development for the school-age child.
The community health nurse reviews data on four families. Which client does the nurse evaluate first?
- A. A preschool-age client whose parent screams profanities at the client.
- B. An adolescent client who watches television all day while the parents operate a busy company.
- C. A school-age client who has poor hygiene, has small-fitting clothes, and has been caught stealing bicycles.
- D. An underweight adolescent client who is following a vegan diet.
Correct Answer: A
Rationale: A preschooler subjected to verbal abuse (screaming profanities) is at high risk for emotional and psychological harm, which can have long-term developmental impacts. This situation requires immediate evaluation to ensure the child's safety, taking priority over neglect, behavioral issues, or dietary concerns.
The nurse is planning care for a client with an intrauterine fetal demise. Which are appropriate goals for this client?
- A. The woman's grieving process will be limited to 6 months.
- B. The woman and her family will discuss plans for going home without the infant.
- C. The woman and her family will express their grief about the loss of their desired infant.
- D. The woman will recognize that thoughts of worthlessness and suicide are normal after a loss.
- E. The woman and her family will contact their pastor or grief counselor for support after discharge.
Correct Answer: B,C,E
Rationale: It is important for the nurse to assess whether the client is undergoing the normal grieving process. Options 2, 3, and 5 are appropriate goals. Signs that are causes for concern and that are not part of the normal grieving process include thoughts of worthlessness and suicide and limiting the grieving process to a short amount of time.
The nurse is caring for a client during a precipitous labor. The nurse should anticipate that the client will require care for which emotional need?
- A. Support in maintaining a sense of control
- B. Less pain and anxiety than with a normal labor
- C. A sense of satisfaction regarding her quick labor
- D. Fewer fears regarding the effect of labor on the newborn infant
Correct Answer: A
Rationale: The client experiencing a precipitous labor may have more difficulty maintaining control because of the abrupt onset and quick progression of the labor. This may be very different from previous labor experiences; therefore, the client needs support from the nurse to understand and adapt to the rapid progression. The contractions often increase in intensity very quickly, which adds to the client's pain, anxiety, and lack of control. The client may also have an increased amount of concern about the effect of the labor on the newborn infant. A lack of control over the situation in combination with increased pain and anxiety can result in a decreased level of satisfaction with the labor and delivery experience.
When the home care nurse arrives, the client with a diagnosis of emphysema is smoking. Which statement by the nurse would be most therapeutic?
- A. Well, I can see you never got to the stop smoking clinic.
- B. Now that your secret is out, may we decide what you are going to do?
- C. Did you explore the stop smoking program at the senior citizens center?
- D. I wonder if you realize that by smoking you are slowly killing yourself.
Correct Answer: C
Rationale: Clients with emphysema must avoid smoking and all airborne irritants. The nurse who observes a maladaptive behavior in a client should not make judgmental comments and should instead explore an adaptive strategy with the client without being overly controlling. This will place the decision making in the client's hands and provide an avenue for the client to share what may be expressions of frustration about an inability to stop what is essentially a physiological addiction. Option 1 is an intrusive use of sarcastic humor that is degrading to the client. Option 2 is a disciplinary remark and places a barrier between the nurse and the client within the therapeutic relationship. In option 4, the nurse preaches and is judgmental.