A nurse is collecting data from an adolescent client who has a conduct disorder.
Which of the following findings is the nurse's priority?

Repeated school absences.

Threats of injury to others.

Lack of empathy for others.

History of shoplifting.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Repeated school absences are a common finding in conduct disorder and indicate a disregard for rules and obligations. While important to address, it does not represent an immediate safety risk compared to threats of harm.

Choice B rationale

Threats of injury to others indicate a potential for violence and pose an immediate safety risk to others. This requires the nurse's immediate attention to assess the situation, ensure safety, and implement appropriate interventions to prevent harm.

Choice C rationale

Lack of empathy for others is a core characteristic of conduct disorder, reflecting a difficulty in understanding or sharing the feelings of others. While significant for long-term management, it does not present an immediate safety concern.

Choice D rationale

A history of shoplifting indicates a pattern of rule-breaking and disregard for the rights of others, which is characteristic of conduct disorder. However, it does not represent an immediate threat of harm compared to threats of injury.

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Correct Answer is ["A","B"]

Explanation

Choice A rationale

Encouraging communication with staff during self-harm urges is a crucial intervention for clients with borderline personality disorder. This allows for immediate support, redirection of focus, and the opportunity to implement coping strategies before an episode of self-harm occurs, aligning with the principles of dialectical behavior therapy often used for this disorder.

Choice B rationale

Assisting the client in developing healthy coping mechanisms for intense emotions is fundamental in managing borderline personality disorder. Individuals with this disorder often experience emotional dysregulation, and learning adaptive coping skills provides them with tools to manage distress, reduce impulsivity, and decrease the likelihood of self-harm.

Choice C rationale

Advising the client to avoid expressing feelings assertively is countertherapeutic. Clients with borderline personality disorder may struggle with expressing emotions appropriately. Encouraging avoidance can lead to suppressed feelings, potential emotional outbursts, and increased risk of self-harm. Assertive communication skills should be fostered.

Choice D rationale

Offering additional attention only when self-mutilating behaviors occur can inadvertently reinforce these behaviors. This approach can create a pattern where the client engages in self-harm to gain attention, rather than learning healthier ways to seek support and manage their emotions. Consistent and proactive support is more effective.

A. Bruises noted in various stages of healing to the face, bilateral arms, and abdomen. B. Laceration to the left cheek cleansed and covered with an adhesive bandage. C. Left shoulder cleansed, antiseptic ointment applied, and covered with gauze dressing. D. Client states, “I fell getting out of the shower and scraped my face and shoulder on the bathroom counter. I tried to catch myself when I fell, and that is how I broke my arm.” E. Client has been married for 22 years and has two children. F. Client works part-time and volunteers at a community center. G. Client is tearful, does not make eye contact, and only speaks when spoken to. H. Client requests not to notify their partner because they do not want them to have to miss work or worry. I. Client reports poor appetite and difficulty sleeping.

Correct Answer is ["A","D","G","H","I"]

Explanation

The findings that indicate possible partner violence and should be reported to the provider include:

Bruises noted in various stages of healing to the face, bilateral arms, and abdomen.
Client is tearful, does not make eye contact, and only speaks when spoken to.
Client reports poor appetite and difficulty sleeping.
Client requests not to notify their partner because they do not want them to have to miss work or worry.
Client states, “I fell getting out of the shower and scraped my face and shoulder on the bathroom counter. I tried to catch myself when I fell, and that is how I broke my arm.”

These signs, particularly the bruising in different healing stages, avoidance of eye contact, emotional distress, reluctance to notify the partner, and vague or inconsistent injury explanations, may indicate potential intimate partner violence. Ensuring proper screening, support, and intervention is crucial in situations like these. The client’s safety and well-being should remain a priority, and reporting these findings to the healthcare provider allows for further assessment and assistance.

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A nurse is collecting data from an adolescent client who has a conduct disorder.Which of the following findings is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who has borderline personality disorder.Which of the following interventions should the nurse recommend?

Correct Answer is ["A","B"]

Explanation

Correct Answer is ["A","D","G","H","I"]

Explanation

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A nurse is collecting data from an adolescent client who has a conduct disorder.
Which of the following findings is the nurse's priority?