A nurse is caring for a client.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.

Answer and Explanation

The Correct Answer is []

Potential Condition The client is most likely experiencing b. Antisocial personality disorder. This is suggested by the client’s lack of remorse, impulsivity, deceitfulness, and aggressive behavior when denied something she wants.

Actions to Take To address this condition, the nurse should:

a. Assess history of criminal behavior: This can provide insight into the severity and pattern of the client’s antisocial behavior.
e. Establish clear and realistic boundaries regarding behavior: This can help manage the client’s impulsivity and aggressive behavior.

Parameters to Monitor To assess the client’s progress, the nurse should monitor:

c. Aggressive and violent behavior: Any reduction in these behaviors can indicate improvement.
e. Deceitfulness: A decrease in deceitful behavior can also signal progress.

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Correct Answer is A

Explanation

Choice A reason:
The Geriatric Depression Scale (GDS) is a valuable tool for screening depression in older adults. Depression is common in this population and can significantly impact their quality of life. The GDS is specifically designed to identify symptoms of depression in the elderly, making it an essential part of the screening process for active older adults. The scale includes a series of questions that help determine the presence and severity of depressive symptoms. Early detection and treatment of depression can improve overall well-being and prevent further complications.

Choice B reason:
The Pain Assessment in Advanced Dementia (PAINAD) Scale is used to assess pain in individuals with advanced dementia who may not be able to communicate their pain verbally. While this tool is crucial for managing pain in dementia patients, it is not typically used for active older adults without dementia. The focus of the PAINAD Scale is on non-verbal cues and behaviors that indicate pain, which may not be relevant for the general active older adult population.

Choice C reason:
The CAGE Questionnaire is a screening tool for identifying potential alcohol abuse. It consists of four questions that help determine if an individual has issues with alcohol consumption. While alcohol abuse can be a concern in older adults, the CAGE Questionnaire is more specific to substance abuse rather than a general health screening for active older adults. It is important, but not as broadly applicable as the Geriatric Depression Scale for this context.

Choice D reason:
The Denver II Developmental Screening Test is designed to assess developmental progress in children from birth to six years old. It evaluates areas such as personal-social, fine motor-adaptive, language, and gross motor skills. This tool is not relevant for screening active older adults, as it is specifically tailored for identifying developmental delays in young children. Therefore, it would not be appropriate for use in a community clinic setting focused on older adults.

A. Encourage the client to attend weekly support group meetings. B. Discuss the appropriate use of assertive behavior with the client. C. Implement measures to prevent intentional self-inflicted injury. D. Assist the client to maintain awareness of her thoughts and feelings.

Correct Answer is C

Explanation

Choice A reason:
The statement "Encourage the client to attend weekly support group meetings" is important for providing social support and reducing feelings of isolation. Support groups can help clients with borderline personality disorder (BPD) share their experiences and learn coping strategies from others facing similar challenges. However, while beneficial, this is not the immediate priority when addressing acute safety concerns.

Choice B reason:
The statement "Discuss the appropriate use of assertive behavior with the client" is valuable for helping clients develop healthier interpersonal skills and reduce impulsive reactions. Assertiveness training can improve communication and reduce conflicts, but it is not the most urgent intervention when the client is at risk of self-harm.

Choice C reason:
The statement "Implement measures to prevent intentional self-inflicted injury" is the correct response. Clients with BPD are at a high risk of self-harm and suicidal behavior. Ensuring the client's safety by implementing measures to prevent self-inflicted injury is the top priority. This includes close monitoring, creating a safe environment, and developing a crisis intervention plan.

Choice D reason:
The statement "Assist the client to maintain awareness of her thoughts and feelings" is essential for long-term management of BPD. Mindfulness and emotional regulation techniques can help clients better understand and manage their emotions. However, this intervention is secondary to addressing immediate safety concerns.

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A nurse is caring for a client. Exhibits Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing screening assessments for active older adult clients at a community clinic. Which of the following tests should the nurse include in the screening?

Correct Answer is A

Explanation

A nurse is planning overall strategies to address problems for a client who has borderline personality disorder. Which of the following strategies is the priority for the nurse to incorporate in the plan of care?

Correct Answer is C

Explanation

A nurse is caring for a client who is prescribed massage therapy to treat panic disorder. The client states, "I can't stand to be touched by another person." Which of the following responses should the nurse make?

A nurse is visiting with the partner of a client who recently died. The partner expresses guilt that they did not do more for their partner. Which of the following responses should the nurse make?

A nurse is caring for a client who begins yelling and pacing around the room. Which of the following actions should the nurse take? (Select all that apply)

A charge nurse is discussing the care of a client who has a substance use disorder with a staff nurse. Which of the following statements by the staff nurse should the charge nurse identify as countertransference?

A nurse is reviewing laboratory results of a client who has schizophrenia and is taking risperidone. For which of the following findings should the nurse notify the provider?

A nurse is caring for a client who has obsessive-compulsive personality disorder. Which of the following findings should the nurse expect?

A nurse is preparing to administer haloperidol 7 mg lIM to a client who is severely agitated. Available is haloperidol injection 5 mg/mL. How manymL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)