A nurse in a mental health facility is caring for a client.
Medical History: Antisocial personality disorder.
Substance use disorder.
Nurses' Notes:. 1400: Client admitted to facility by court order for evaluation following arrest for disorderly conduct and resisting arrest.
Client states, "That judge is so stupid.
I don't belong here!" Client has rigid posture, is pacing around the room attempting to intimidate staff and other clients on the unit.
Extra staff members gather.
1500: Client escorted to room.
Client becomes flirtatious with assistant personnel (AP). Client introduced to roommate, whom they ignore.
Continues to flirt with AP. 1800: Client refuses to go to dining room for dinner.
States, "I'm not sitting down with a bunch of nuts.
Bring my food to me!". For each potential nursing action, click to specify if the potential action is anticipated or contraindicated for the client.
Use bargaining to improve behavior.
Provide rewards for positive behavior.
Ignore negative behavior.
Maintain a low-stimuli environment.
The Correct Answer is B
Choice A rationale:
Using bargaining to improve behavior is not recommended for individuals with Antisocial Personality Disorder. It can reinforce manipulative behaviors.
Choice B rationale:
Providing rewards for positive behavior can be beneficial. It can encourage the development of healthier behaviors.
Choice C rationale:
Ignoring negative behavior is not recommended. It’s important to address these behaviors directly and establish clear consequences.
Choice D rationale:
Maintaining a low-stimuli environment can be beneficial for individuals with Antisocial Personality Disorder. It can help reduce agitation and aggressive behaviors.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Ensuring the client goes to group activities as planned is important, but not the priority when the client is confused and has distorted thinking.
Choice B rationale:
Using distraction such as television or music can be helpful, but it is not the priority intervention.
Choice C rationale:
Providing reassurance and comfort ensuring the client is safe is the priority as it directly addresses the client’s immediate needs.
Choice D rationale:
Giving PRN medications to treat increased hallucinations may be necessary, but it is not the first action to take.
Correct Answer is A
Explanation
Choice A rationale:
Twisting tongue movements are a common symptom of tardive dyskinesia (TD), a side effect of long-term use of antipsychotic medications like fluphenazine.
Choice B rationale:
Shuffling gait is more commonly associated with Parkinson’s disease and certain antipsychotic medications can cause Parkinson-like symptoms, but it is not a characteristic of TD2.
Choice C rationale:
Sudden onset of high fever is not associated with TD. It could be a sign of a serious condition like neuroleptic malignant syndrome, which requires immediate medical attention.
Choice D rationale:
Constant tapping of feet when sitting could be a sign of restlessness or akathisia, another potential side effect of antipsychotic medications, but it is not a specific sign of TD2.
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