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When assessing a client diagnosed with major depressive disorder who states, 'I feel like I can't go on,' which of the following actions should the nurse take first?
- A. Administer a prescribed antidepressant medication.
- B. Ask the client if they have a plan to commit suicide.
- C. Encourage the client to attend a support group.
- D. Contact the client's family to provide support.
Correct Answer: B
Rationale: The priority action for the nurse is to assess the client's risk for suicide. By asking if the client has a plan to commit suicide, the nurse can determine the immediate safety of the client and take appropriate interventions to prevent harm. Administering antidepressant medication is not the first action to take in this situation as assessing the client's safety is the priority. Encouraging the client to attend a support group or contacting the client's family, although beneficial, are not immediate actions to ensure the client's safety in a crisis situation.
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A patient presents in the Emergency Department immediately following a shooting incident in a school where she has been teaching. There is no evidence of physical injury, but she appears very hyperactive and talkative. Which of these symptoms manifested by the patient is an uncommon initial biological response to stress?
- A. Constricted pupils
- B. Watery eyes
- C. Palpitations
- D. Increased heart rate
Correct Answer: A
Rationale: Increased lacrimal secretions, palpitations, and increased heart rate are common initial biological responses to stress. Constricted pupils are not typical in the initial response to stress and are more associated with the opposite response, the Rest and Digest system. Watery eyes, palpitations, and increased heart rate are indicative of the body's fight or flight response to stress. Unusual food cravings are not a typical biological response to stress.
A client has been diagnosed with histrionic personality disorder. Which of the following behaviors should the nurse expect?
- A. Attention-seeking behavior
- B. Dramatic expressions of emotion
- C. Seductive behavior
- D. Dependency on others
Correct Answer: A
Rationale: Individuals with histrionic personality disorder often display attention-seeking behaviors as a way to draw focus and validation from others. This behavior may manifest as exaggerated emotions and dramatic expressions to maintain the spotlight. While seductive behavior and dependency on others are potential characteristics of histrionic personality disorder, attention-seeking behavior is the hallmark trait. Therefore, the correct answer is attention-seeking behavior (Choice A). Dramatic expressions of emotion (Choice B) can be a feature of histrionic personality disorder, but it is not as characteristic as attention-seeking behavior. Seductive behavior (Choice C) may also be present in individuals with histrionic personality disorder, but it is not the primary behavior to expect. Dependency on others (Choice D) is not a core feature of histrionic personality disorder, although individuals with this disorder may seek attention and validation from others.
A healthcare provider is assessing a client diagnosed with antisocial personality disorder. Which of the following behaviors should the provider expect the client to exhibit?
- A. A lack of remorse for wrongdoing
- B. A fear of gaining weight
- C. A need for constant reassurance
- D. A willingness to take responsibility for actions
Correct Answer: A
Rationale: Individuals with antisocial personality disorder typically exhibit a lack of remorse for their actions. They may disregard the rights of others, engage in deceitful and manipulative behaviors, and show a consistent pattern of irresponsibility and disregard for social norms. This behavior is a key characteristic of this disorder. Choices B, C, and D are incorrect because they do not align with the typical behaviors associated with antisocial personality disorder. Fear of gaining weight is more indicative of an eating disorder rather than antisocial personality disorder. Needing constant reassurance is not a common trait of individuals with antisocial personality disorder. Additionally, individuals with this disorder often avoid taking responsibility for their actions.
A client with obsessive-compulsive disorder (OCD) tells the nurse, 'I know my behavior is unreasonable, but I can't help it.' What response should the nurse provide?
- A. Your behavior is part of your illness, and it is important to work on changing it.
- B. It is important to understand why you feel the need to perform these behaviors.
- C. Let's figure out a way for you to control these behaviors.
- D. It sounds like you are feeling powerless to change your behavior.
Correct Answer: D
Rationale: The nurse should acknowledge the client's awareness of the irrationality of their behavior and the feeling of powerlessness to change it. By reflecting the client's feelings, the nurse validates them and opens a discussion on strategies to manage the behavior effectively. Empathy and understanding are key in supporting clients with OCD. Choice A is incorrect because it focuses more on changing the behavior rather than acknowledging the client's feelings. Choice B is incorrect as it does not directly address the client's sense of powerlessness. Choice C is incorrect as it doesn't validate the client's feelings of being unable to control the behaviors.
Which of the following interventions should be implemented for a client with anorexia nervosa? Select one that does not apply.
- A. Monitor daily caloric intake and weight
- B. Establish a structured eating plan
- C. Encourage the client to exercise
- D. Provide liquid supplements as prescribed
Correct Answer: C
Rationale: Interventions for a client with anorexia nervosa include monitoring daily caloric intake and weight, establishing a structured eating plan, providing liquid supplements as prescribed, and offering rewards for weight gain. However, encouraging the client to exercise is not appropriate as it may exacerbate the condition by increasing caloric expenditure and reinforcing unhealthy behaviors associated with the disorder. Exercise may further contribute to excessive weight loss and worsen the client's physical health in the context of anorexia nervosa.