When a client with a personality disorder uses self-destructive behavior as a way of getting needs met, the staff observe the behavior closely because:

It is required to ensure the safety of the client and others.

It indulges the client’s wishes.

It provides an outlet for feelings of anger and frustration.

The client’s anger and anxiety will be decreased if staff assume responsibility for the client’s behavior.

Answer and Explanation

The Correct Answer is A

Choice A Reason:

When a client with a personality disorder engages in self-destructive behavior, it is crucial for the staff to observe this behavior closely to ensure the safety of both the client and others around them. Self-destructive behaviors can include actions such as self-harm, substance abuse, or reckless activities that pose a significant risk to the individual’s well-being. By monitoring these behaviors, staff can intervene promptly to prevent harm and provide necessary support. Ensuring safety is a fundamental aspect of care in mental health settings, as it helps to stabilize the client and create a secure environment for their treatment and recover.

Choice B Reason:

Indulging the client’s wishes is not a recommended approach when dealing with self-destructive behavior. While it is important to understand and validate the client’s feelings, indulging their wishes can reinforce negative behaviors and hinder their progress towards healthier coping mechanisms. Instead, staff should focus on providing appropriate interventions and support that address the underlying issues contributing to the self-destructive behavior. This approach helps the client develop more constructive ways of meeting their needs and managing their emotions.

Choice C Reason:

While self-destructive behavior may provide a temporary outlet for feelings of anger and frustration, it is not a healthy or sustainable way to cope with these emotions. Encouraging or allowing such behavior can lead to further harm and exacerbate the client’s mental health issues. Staff should work with the client to identify and implement healthier coping strategies that effectively address their emotional needs without causing harm. This can include therapeutic interventions, counseling, and skills training to help the client manage their anger and frustration in more constructive ways.

Choice D Reason:

Assuming responsibility for the client’s behavior is not an effective way to reduce their anger and anxiety. In fact, it can create a dependency on staff and prevent the client from developing their own coping skills and sense of autonomy. It is important for staff to support the client in taking responsibility for their actions and learning how to manage their emotions independently. This empowerment is a key component of the therapeutic process and contributes to the client’s long-term recovery and well-being.

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Correct Answer is ["2"]

Explanation

Step 1: Identify the dosage required and the concentration available.

Required dosage: 40 mg
Available concentration: 20 mg/mL

Step 2: Calculate the volume to be administered.

Volume to be administered = Required dosage ÷ Available concentration
Volume to be administered = 40 mg ÷ 20 mg/mL

Step 3: Perform the division.

Volume to be administered = 40 ÷ 20
Volume to be administered = 2 mL

Step 4: Round the answer to the nearest whole number (if necessary).

Volume to be administered = 2 mL (no rounding needed)

The nurse should administer 2 mL.

A. Distinct wound borders to plantar aspect of foot B. +3 edema to the mid-calf C. Patient reports 9 (0-10) pain scale to area D. Irregular wound borders E. Minimal serous drainage

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

Explanation

b. +3 edema to the mid-calf

d. Irregular wound borders

e. Minimal serous drainage

Explanation of Choices

Choice A Reason: Distinct Wound Borders to Plantar Aspect of Foot

Venous ulcers typically present with irregular wound borders rather than distinct ones. They are usually found on the lower legs, particularly around the medial malleolus (inner ankle), rather than the plantar aspect of the foot. The plantar aspect of the foot is more commonly associated with diabetic ulcers or pressure sores. Therefore, distinct wound borders to the plantar aspect of the foot are not indicative of a venous ulcer.

Choice B Reason: +3 Edema to the Mid-Calf

Edema, or swelling, is a common finding in patients with venous ulcers. Venous insufficiency leads to increased pressure in the veins, causing fluid to leak into the surrounding tissues, resulting in edema. The presence of +3 edema (a significant level of swelling) in the mid-calf is a strong indicator of venous insufficiency and, consequently, venous ulcers. This finding supports the diagnosis of a venous ulcer.

Choice C Reason: Patient Reports 9 (0-10) Pain Scale to Area

While pain can be associated with venous ulcers, it is not a definitive diagnostic criterion. Pain levels can vary widely among individuals with venous ulcers, and some may experience minimal discomfort. A pain scale rating of 9 out of 10 indicates severe pain, which could be due to various conditions, not specifically venous ulcers. Therefore, this finding alone is not sufficient to suspect a venous ulcer.

Choice D Reason: Irregular Wound Borders

Venous ulcers are characterized by their irregular wound borders. Unlike arterial ulcers, which have well-defined edges, venous ulcers tend to have uneven, irregular borders. This is due to the chronic nature of venous insufficiency and the ongoing damage to the skin and underlying tissues. The presence of irregular wound borders is a key indicator of a venous ulcer.

Choice E Reason: Minimal Serous Drainage

Venous ulcers often produce serous drainage, which is a clear to pale yellow fluid. The amount of drainage can vary, but minimal serous drainage is a common finding. This type of drainage is due to the chronic inflammation and fluid leakage associated with venous insufficiency. Therefore, minimal serous drainage is consistent with the presence of a venous ulcer.

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When a client with a personality disorder uses self-destructive behavior as a way of getting needs met, the staff observe the behavior closely because:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer fluoxetine 40 mg PO daily. The amount available is fluoxetine 20 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["2"]

Explanation

Which of the following assessment findings would lead the nurse to suspect the client has a venous ulcer to the right lower extremity? (SELECT ALL THAT APPLY)

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

Explanation

An individual with a history of antisocial personality disorder was arrested for driving under the influence of alcohol and causing a serious car accident. Which comment on this behavior would be expected?

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