Nursing Elites

1. Which of the following interventions is essential when working with a client who has antisocial personality disorder?

• A. Monitor intake and output
• B. Set strict limits on behavior
• C. Provide diversion for the client
• D. Limit visits from family or friends

Correct answer: B

Rationale: When working with a client diagnosed with antisocial personality disorder, it is crucial to set strict limits on their behavior. This disorder is characterized by manipulative behavior, impulsivity, and deceitfulness. By setting strict limits, the nurse can establish boundaries to prevent the client from manipulating others or engaging in disruptive behaviors. Monitoring intake and output (Choice A) is not directly related to managing antisocial personality disorder. Providing diversion (Choice C) or limiting visits from family or friends (Choice D) may not address the core issues associated with this disorder, such as manipulation and boundary violations.

2. After being medicated for anxiety, the client says to the nurse, 'I guess you are too busy to stay with me.' Which response by the nurse is correct?

• A. I'm so sorry, but I need to see other clients.'
• B. 'I have to go now, but I will come back in 10 minutes.'
• C. You'll be able to rest after the medicine starts working.'
• D. You'll feel better after I've made you more comfortable.'

Correct answer: B

Rationale: The nurse should respond with empathy and reassurance to address the client's emotional needs. The correct response, 'I have to go now, but I will come back in 10 minutes,' acknowledges the client's feelings while providing a timeframe for the nurse's return, showing care and concern. Choice A, 'I'm so sorry, but I need to see other clients,' prioritizes other tasks over the client's emotional needs, which can increase anxiety. Choice C, 'You'll be able to rest after the medicine starts working,' offers false reassurance and does not address the client's immediate emotional distress. Choice D, 'You'll feel better after I've made you more comfortable,' does not acknowledge the client's concerns and fails to establish a supportive connection with the client.

3. The best way for a healthcare provider and a healthcare facility to control the effects of poor and disruptive patient behavior is to _________________.

• A. prevent it
• B. restrain the patient
• C. medicate the patient
• D. isolate the patient

Correct answer: A

Rationale: The most effective approach to managing poor and disruptive patient behavior is by preventing it proactively. This involves implementing strategies, communication techniques, and environmental modifications that address the underlying causes of the behavior. Restraint, medication, and isolation should only be used as a last resort when the patient or others are at risk of harm. Restraint and isolation are primarily used to ensure safety, while medication, especially when used solely to control behavior, can have adverse effects and is considered a measure of last resort. Therefore, prevention is crucial in promoting a therapeutic environment and fostering positive patient outcomes.

4. An ambulatory client reports edema during the day in his feet and an ankle that disappears while sleeping at night. What is the most appropriate follow-up question for the nurse to ask?

• A. Have you had a recent heart attack?
• B. Do you become short of breath during your normal daily activities?
• C. How many pillows do you use at night to sleep comfortably?
• D. Do you smoke?

Correct answer: B

Rationale: The correct answer is asking about shortness of breath during normal daily activities because these symptoms suggest right-sided heart failure, leading to increased pressure in the systemic venous system. This pressure causes fluid to shift into the interstitial spaces, resulting in edema. In an ambulatory patient, lower extremities are typically affected first due to gravity. By asking about shortness of breath, the nurse can gather information to confirm the nursing diagnosis of activity intolerance and fluid volume excess, both associated with right-sided heart failure. The other choices are less relevant in this context and do not directly address the client's presenting symptoms.

5. Why is it important for the nurse to inform the family about the client's situation?

• A. To decrease the client's anxiety
• B. To help the family better adapt to necessary role changes
• C. To improve communication between family and nursing staff
• D. To ensure a more relaxed atmosphere for the client

Correct answer: B

Rationale: It is crucial for the nurse to inform the family about the client's situation to help them better adapt to necessary role changes. By providing early notification, the family can start preparing for potential adjustments. While reducing the client's anxiety and improving communication with the nursing staff are important, the primary purpose is to assist the family in undertaking the required role changes. Creating a relaxed atmosphere for the client, although beneficial, is not the main objective in this situation.

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