A mental health nurse is caring for a client with Antisocial Personality Disorder who attacked one of her friends and is admitted to the psychiatric unit.
Which of the following actions should the nurse take first?
Explain to the client that the behavior was unacceptable.
Set behavioral limits for the client.
Explore the truth of the client's statements.
Establish a client relationship.
The Correct Answer is D
Rationale for Choice A:
While it is important to address the client's behavior, simply explaining that it was unacceptable is unlikely to be effective in this situation. Clients with antisocial personality disorder often have difficulty understanding and accepting responsibility for their actions. They may lack empathy for others and may not see their behavior as problematic. Confronting the client about their behavior too early in the therapeutic relationship could lead to defensiveness, hostility, or even aggression. It is important to first establish a rapport with the client and build a foundation of trust before addressing difficult topics.
Rationale for Choice B:
Setting behavioral limits is an important aspect of treatment for clients with antisocial personality disorder. However, it is not the first priority in this situation. Before setting limits, the nurse needs to establish a relationship with the client and assess their individual needs and level of functioning. Attempting to set limits without first establishing a rapport could lead to power struggles and further resistance from the client.
Rationale for Choice C:
Exploring the truth of the client's statements may be necessary at some point in the treatment process. However, it is not the first priority in this situation. The nurse's initial focus should be on establishing a relationship with the client and assessing their immediate needs. Focusing on the accuracy of the client's statements too early in the therapeutic process could derail the development of a trusting relationship.
Rationale for Choice D:
Establishing a client relationship is the first and most important step in the treatment of any client, but it is especially crucial for clients with antisocial personality disorder. These clients often have difficulty trusting others and forming close relationships. By establishing a rapport with the client, the nurse can begin to build trust and create a safe and supportive environment. This foundation is essential for any further therapeutic interventions to be successful.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"A"}}
Explanation
The correct answer/s is Choice/s.
Choice A rationale: Mental health support is generally considered a protective factor against suicide. Effective mental health care can help individuals manage their mental health conditions, which can reduce the risk of suicide.
Choice B rationale: Family history, particularly a family history of suicide, is a risk factor for suicide. The client’s mother’s suicide could potentially increase the client’s risk.
Choice C rationale: Good physical health is typically seen as a protective factor against suicide. Serious physical health conditions, including chronic pain, can increase suicide risk, but the client is reported to be in good physical health.
Choice D rationale: Support systems, such as feeling connected to family and community, are protective factors against suicide. They can provide emotional support and help individuals feel less isolated.
Choice E rationale: Alcohol consumption, especially misuse or addiction, is a risk factor for suicide. However, the client has attended rehabilitation and has not used alcohol for the past 4 years, which could be seen as a protective factor.
Choice F rationale: Access to lethal means is a risk factor for suicide. Limiting access to lethal means is a societal protective factor.
Correct Answer is C
Explanation
Choice A rationale: Initiating vomiting and applying an enema is not the first action to take when finding an unconscious person. This could potentially cause more harm, especially if the person is unconscious as they could choke. It’s also important to note that inducing vomiting is not a recommended procedure for drug overdoses as it can lead to aspiration, which can cause more harm.
Choice B rationale: Checking pupil size and reflexes is important in assessing a patient’s neurological status. However, it is not the first action to take. The first action should always be to ensure the patient has a patent airway to allow for adequate oxygenation.
Choice C rationale: Establishing a patent airway is the correct first action when finding an unconscious person. This is because maintaining a patent airway is crucial for oxygenation and ventilation. Without a patent airway, the person could suffer from hypoxia, which could lead to brain damage or death.
Choice D rationale: Administering IV fluids fast is not the first action to take when finding an unconscious person. While IV fluids may be necessary later on in the management of the patient, the first action should always be to ensure the patient has a patent airway.
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