A nurse is assessing a client who has antisocial personality disorder. Which of the following manifestations should the nurse expect?

Self-mutilation

Social isolation

Paranoid ideation

Lack of empathy

Answer and Explanation

The Correct Answer is D

Rationale:

A. Self-mutilation: This behavior is more commonly associated with borderline personality disorder. Individuals with borderline traits may engage in self-harm as a means of emotional regulation or response to abandonment fears, not typical in antisocial personality disorder.

B. Social isolation: Clients with antisocial personality disorder are often socially manipulative and may actively engage with others for personal gain. They are typically not socially withdrawn but can be superficially charming and exploitative.

C. Paranoid ideation: Paranoia is more closely linked with paranoid or schizotypal personality disorders. While someone with antisocial traits may be suspicious if it serves their manipulative purposes, persistent paranoid ideation is not a defining feature.

D. Lack of empathy: A hallmark feature of antisocial personality disorder is a disregard for others' feelings, rights, and safety. These clients often exhibit a lack of remorse and empathy, making them prone to violating social norms and laws without guilt.

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Correct Answer is A

Explanation

Rationale:

A. The client has a wound dressing saturated with sanguinous drainage after it was reinforced: Continued sanguineous drainage that saturates reinforced dressings just 2 hours post-op may indicate active bleeding or hemorrhage. This is an urgent finding that requires immediate provider notification for assessment and possible intervention.

B. The client reports a pain level of 2 on a 0 to 10 scale after administration of pain medication: A pain score of 2 reflects adequate pain control following intervention. This is an expected and desirable outcome and does not require provider notification.

C. The client has a urine output of 50 mL/hr after removal of the indwelling urinary catheter: A urine output of 50 mL/hr is within normal limits and suggests appropriate renal perfusion. No immediate action or provider notification is required based on this finding.

D. The client has an oxygen saturation level of 96% after oxygen 2 L/min via nasal cannula was applied: This oxygen saturation level indicates adequate oxygenation with supplemental oxygen and is within expected postoperative parameters.

A. Make an audio recording of the adolescent's responses B. Promise not to disclose information shared during the interview C. Obtain a history from both the adolescent and their caregiver. D. Use leading questions during the interview.

Correct Answer is C

Explanation

Rationale:

A. Make an audio recording of the adolescent's responses: Audio recordings require consent and may not be legally or ethically appropriate in suspected abuse cases. Documentation should be written, factual, and follow institutional policies and mandatory reporting laws.

B. Promise not to disclose information shared during the interview: Nurses must never promise confidentiality in suspected abuse cases, as they are mandated reporters. All disclosures of abuse must be reported to child protective services or appropriate authorities.

C. Obtain a history from both the adolescent and their caregiver: Gathering information from both parties helps identify inconsistencies and assess the situation fully. However, this should be done separately to allow the adolescent to speak freely and without coercion.

D. Use leading questions during the interview: Leading questions can influence the adolescent’s responses and compromise the integrity of the assessment. Open-ended, nonjudgmental questions are essential to support accurate and unbiased information gathering.

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Finding	Nursing Intervention
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A nurse is assessing a client who has antisocial personality disorder. Which of the following manifestations should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

Explanation

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