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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 being easily bored, shallow relationships, attention-seeking (C), and impulsivity, mood shifts, and manipulative behavior (D). Options A and E describe Cluster A, and B describes Cluster C.
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A client with a history of pulmonary emboli is scheduled for the insertion of an inferior vena cava filter. The nurse checks on the client 1 hour after the primary health care provider has explained the procedure and obtained informed consent from the client. The client is lying in bed, wringing his hands, and states to the nurse, 'I'm not sure about this. What if it doesn't work and I'm just as bad off as before?' Which concern for the client should the nurse identify at this time?
- A. Anxiety and depression
- B. Inability to handle the treatment regimen
- C. Lack of knowledge about the surgical procedure
- D. Fear about the potential risks and outcomes of surgery
Correct Answer: D
Rationale: This client has indicated the surgical procedure and its outcome as the object of fear. Anxiety is present when the client cannot identify the source of the uneasy feelings. Presently there are not indications that the client is depressed. A client's inability to handle a treatment regimen would be when the client is not making needed adaptations to deal with daily life. Lack of knowledge would be when there is a lack of appropriate information.
A client is demonstrating confusion as a result of bed rest and a prolonged length of hospital stay. The client receives a prescription for progressive ambulation as tolerated. Which is the best nursing intervention to use to implement the prescription?
- A. Ambulate to the client's bathroom three times a day.
- B. Ambulate in the room for short distances frequently.
- C. Ambulate in the hall progressively three times a day.
- D. Assist with range-of-motion exercises three times a day.
Correct Answer: C
Rationale: The cause of the client's confusion is bed rest and decreased sensory stimulation from a prolonged length of stay; therefore, the best intervention is to ambulate the client in the hall to increase sensory stimulation. Hopefully the stimulation can help decrease the confusion. Options 1 and 2 do not address the client's need for sensory stimulation. The nurse performs option 4 in preparation for ambulation while the client is on bed rest.
The nurse is caring for a client in the psychiatric unit who has issues with coping and defense mechanisms. The nurse understands that which is true regarding coping and defense mechanisms? Select all that apply.
- A. Coping mechanisms are destructive ways to avoid dealing with reality.
- B. Physical symptoms, general irritability, and self-destructive behaviors are some of the signs of inadequate coping.
- C. Criticizing ineffective defense mechanisms will guide the client toward better coping techniques.
- D. Ineffective coping mechanisms allow anxiety to increase, triggering the client to utilize defense mechanisms in order to protect himself from the anxiety.
- E. The inability to cope can be caused by a lack of an adequate support system, a serious medical diagnosis, situational crises, or a lack of psychological resources.
Correct Answer: B,D,E
Rationale: Coping mechanisms are constructive, not destructive, making A incorrect. Criticizing defense mechanisms is nontherapeutic, making C incorrect. Signs of inadequate coping, anxiety escalation, and causes of poor coping are accurate.
A nurse in the outpatient clinic receives four phone messages. Which call does the nurse return first?
- A. The parent of a preschool-age child who continuously throws temper tantrums, is always moving, and is impulsive.
- B. The parent whose adolescent child has vomited every day for 2 weeks and now weighs 74 pounds.
- C. The parent who receives calls from the school about an adolescent child's aggressive behavior toward schoolmates.
- D. The adult child of an older adult who is having difficulty sleeping after a spouse died 2 weeks ago.
Correct Answer: B
Rationale: An adolescent vomiting daily for 2 weeks and weighing 74 pounds indicates a critical health issue, likely severe dehydration or malnutrition, requiring urgent assessment to prevent life-threatening complications. This takes priority over behavioral, aggression, or grief-related concerns.
A client who is to be discharged to home with a temporary colostomy states to the nurse, 'I know I've changed this thing once, but I just don't know how I'll do it by myself when I'm home alone. Can't I stay here until the surgeon puts it back?' Which therapeutic response should the nurse make to best deal with the client's concerns?
- A. This is only temporary, but with your level of anxiety you need to hire a nurse companion until your surgery.'
- B. So you're saying that, although you've practiced changing your colostomy bag once, you don't feel comfortable on your own yet?'
- C. Well, your insurance will not pay for a longer stay just to practice changing your colostomy, so you'll have to fight it out with them.'
- D. Going home to care for yourself still feels pretty overwhelming? I will schedule you for home visits until you're feeling more comfortable.'
Correct Answer: D
Rationale: The client is expressing feelings of fear and helplessness. Option 4 assists with meeting this client's needs. Option 1 provides information that the client already knows and then problem-solves by using a client-centered action, which would probably overwhelm the client. Option 2 is restating, but this response could cause the client to feel more helpless because the client's fears are reflected back to the client. Option 3 provides what is probably accurate information, but the words 'just to practice' can be interpreted by the client as belittling.