Which of the following approaches would be most appropriate to use with a client suffering from narcissistic personality disorder when discrepancies exist between what the client states and what actually exist?
-
Solution
Supportive confrontation
Option B: The nurse would specifically use supportive confrontation with the client to point out discrepancies between what the client states and what actually exists to increase responsibility for self.
Joey a client with antisocial personality disorder belches loudly. A staff member asks Joey, “Do you know why people find you repulsive?” this statement most likely would elicit which of the following client reaction?
-
Solution
Defensiveness
Option A: When the staff member ask the client if he wonders why others find him repulsive, the client is likely to feel defensive because the question is belittling. The natural tendency is to counterattack the threat to self image.
Conney with borderline personality disorder who is to be discharged soon threatens to “do something” to herself if discharged. Which of the following actions by the nurse would be most important?
-
Solution
Discuss the meaning of the client’s statement with her
Option B: Any suicidal statement must be assessed by the nurse. The nurse should discuss the client’s statement with her to determine its meaning in terms of suicide.
Mario is complaining to other clients about not being allowed by staff to keep food in his room. Which of the following interventions would be most appropriate?
-
Solution
Setting limits on the behavior
Option D: The nurse needs to set limits on the client’s manipulative behavior to help the client control dysfunctional behavior. A consistent approach by the staff is necessary to decrease manipulation.
A 39-year-old mother with obsessive-compulsive disorder has become immobilized by her elaborate hand washing and walking rituals. Nurse Trish recognizes that the basis of O.C. disorder is often:
-
Solution
Feelings of guilt and inadequacy
Option C: Ritualistic behavior seen in this disorder is aimed at controlling guilt and inadequacy by maintaining an absolute set pattern of behavior.
Nurse Anna can minimize agitation in a disturbed client by:
-
Solution
limiting unnecessary interaction
Option B: Limiting unnecessary interaction will decrease stimulation and agitation.
Nurse Patricia is aware that the major health complication associated with intractable anorexia nervosa would be…
-
Solution
Cardiac dysrhythmias resulting in cardiac arrest
Option A: These clients have severely depleted levels of sodium and potassium because of their starvation diet and energy expenditure, these electrolytes are necessary for cardiac functioning.
Nurse Trish is working in a mental health facility; the nurse’s priority nursing intervention for a newly admitted client with bulimia nervosa would be…
-
Solution
Monitor client continuously
Option D: These clients often hide food or force vomiting; therefore they must be carefully monitored.
A 75-year-old client is admitted to the hospital with the diagnosis of dementia of the Alzheimer’s type and depression. The symptom that is unrelated to depression would be?
-
Solution
Shallow of labile effect
Option C: With depression, there is little or no emotional involvement therefore little alteration in affect.
A neuromuscular blocking agent is administered to a client before ECT therapy. The Nurse should carefully observe the client for…
-
Solution
Respiratory difficulties
Option A: Neuromuscular Blocker, such as SUCCINYLCHOLINE (Anectine) produces respiratory depression because it inhibits contractions of respiratory muscles.