A nurse is assessing a client who states that she becomes extremely anxious in social gatherings. She tells the nurse that she never feels "good enough" for her coworkers.
The nurse should identify that these findings can indicate which of the following personality disorders.

Choice A rationale

Documenting a summary of data at the change of shift is a critical component of interprofessional communication, ensuring continuity of care. However, initial charting should be done promptly after data collection to maintain accuracy and prevent errors. Delaying documentation can lead to misinterpretation or omission of crucial information regarding the client's condition and needs. This practice ensures all members of the healthcare team are informed.

Choice B rationale

Noting whether a client has a living will is a fundamental ethical and legal obligation. This advance directive provides a written expression of a client’s wishes regarding medical treatment, which must be respected and documented in the medical record. It guides the healthcare team's decisions and ensures that the client's autonomy and right to self-determination are upheld.

Choice C rationale

Evaluation is the final step of the nursing process, following assessment, diagnosis, planning, and implementation. The nurse must first collect objective and subjective data, then analyze it before determining an appropriate plan of care. Beginning with an evaluation would bypass the essential steps of data collection and analysis, leading to an inaccurate or unsafe plan of care.

Choice D rationale

While assistive personnel can collect vital signs, the nurse is professionally and legally responsible for the data's accuracy and interpretation. The nurse must verify the data, analyze trends, and ensure it is documented accurately and promptly. The nurse is ultimately accountable for any actions taken based on this data, making proper documentation and validation essential.

Choice A rationale

Visual disturbances are a less common side effect of risperidone and are not typically considered a priority finding. While they can be a nuisance for the client, they do not pose an immediate threat to the client's life. Other side effects require more immediate attention and intervention from the healthcare provider.

Choice B rationale

Risperidone can cause cardiac side effects such as QT prolongation, which can lead to life-threatening arrhythmias like Torsades de pointes. An irregular pulse is a critical finding that could indicate an underlying cardiac issue and requires immediate evaluation. This is a priority finding for the nurse to report to the provider.

Choice C rationale

Constipation is a common side effect of risperidone due to its anticholinergic properties. While it can cause discomfort, it is not an immediate life-threatening condition. The nurse should address this by encouraging fluid and fiber intake and possibly discussing a stool softener with the provider, but it is not the highest priority.

Choice D rationale

Dry mouth is a common and relatively benign side effect of risperidone. While it can cause discomfort and increase the risk of dental caries, it is not an urgent or life-threatening condition. The nurse can advise the client on strategies to manage this symptom, such as using sugar-free candies or chewing gum. *.