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A nurse is assisting in the care of a client in the emergency department (ED). Nurses' Notes 0205: Client brought to the ED by police after being found wandering on the street.

Client able to provide identity to police but not able to identify place or time.

Family notified.

Client confused and agitated.

Appearance is disheveled.

Mucous membranes dry.

Lungs clear and equal, heart rhythm regular.

During data collection, the client states, "Can you ask that person to leave my room?" Client is pointing to an empty chair.

Vital Signs 0200: Temperature 38.6°C (101.5°F), Heart rate 104/min, Respiratory rate 18/min, Blood pressure 158/96 mm Hg, Oxygen saturation 98% on room air.

Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again.

Client confused and agitated.

Appearance is disheveled.

Mucous membranes dry

client states, "Can you ask that person to leave my room?"

Client is pointing to an empty chair

Temperature 38.6°C (101.5°F)

Blood pressure 158/96 mm Hg

Answer and Explanation

The Correct Answer is ["A","B","C","D","E","F","G"]

The findings that require immediate follow-up are: Client confused and agitated: This could indicate a neurological issue or other serious condition that needs immediate attention.
Appearance is disheveled: This could suggest neglect or other issues that need to be addressed.
Mucous membranes dry: This could indicate dehydration which can be serious if not addressed promptly. Client states “Can you ask that person to leave my room?” Client is pointing to an empty chair: This could indicate hallucinations or other mental health concerns that need immediate attention.
Temperature 38.6°C (101.5°F): This is a fever and could indicate an infection or other medical condition that needs immediate attention.
Blood pressure 158/96 mm Hg: This is high and could indicate hypertension or other cardiovascular issues that need immediate attention.

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is ["B","C","D","E"]

Explanation

Choice A rationale:

Preoccupation with details is more commonly associated with obsessive-compulsive personality disorder, not antisocial personality disorder.

Choice B rationale:

Manipulative behaviors are a common characteristic of antisocial personality disorder. Individuals with this disorder often manipulate others for personal gain.

Choice C rationale:

Splitting, or viewing others as all good or all bad, is a defense mechanism often used by individuals with antisocial personality disorder.

Choice D rationale:

Impulsiveness is a common characteristic of antisocial personality disorder. Individuals with this disorder often act without considering the consequences.

Choice E rationale:

Lack of empathy is a common characteristic of antisocial personality disorder. Individuals with this disorder often have difficulty understanding or sharing the feelings of others.

A. Excessively anxious. B. Withdrawn behaviors. C. Exploitive of others. D. Blunted affect.

Correct Answer is C

Explanation

Choice A rationale:

Excessive anxiety is not typically associated with antisocial personality disorder. It is more commonly seen in anxiety disorders.

Choice B rationale:

Withdrawn behaviors are more commonly associated with disorders such as depression or social anxiety disorder, not antisocial personality disorder.

Choice C rationale:

Exploiting others is a common characteristic of antisocial personality disorder. Individuals with this disorder often manipulate or deceive others for personal gain.

Choice D rationale:

Blunted affect, or reduced emotional expression, is not typically associated with antisocial personality disorder. It is more commonly seen in disorders such as schizophrenia.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has antisocial personality disorder. Which of the following findings should the nurse expect? (Select all that apply.) .

Correct Answer is ["B","C","D","E"]

Explanation

A nurse is collecting data for a health history from a client who has antisocial personality disorder. Which of the following clinical findings is associated with this disorder?.

Correct Answer is C

Explanation

A nurse is caring for a client who has depressive disorder following the recent death of their partner. Which of the following responses should the nurse make?.

The nurse has reviewed the nurses' notes, provider's note, and vital signs at 0400. Exhibits For each potential provider prescription, click to specify if the prescription is expected or unexpected for the client.

A nurse is reinforcing behavior management techniques with the parent of a school-age child who has conduct disorder. Which of the following statements by the parent indicates an understanding of the redirection technique? .

A nurse is caring for a client who is experiencing a situational crisis. Which of the following actions should the nurse take first?.

A nurse is collecting data from an adult client in an outpatient mental health clinic. The nurse should identify which of the following events as a potential cause of a maturational crisis?.

A nurse is providing information to a client about smoking cessation. Which of the following medications should the nurse include?.

A nurse in a substance use disorder clinic is explaining the alcohol recovery process to a client's family. Which of the following should the nurse identify as the first step toward successful recovery from alcohol use disorder?.