When working with individuals who have a personality disorder. The nurse is aware of the importance of incorporating which nursing measures. (Select all that apply).
Challenge the patient at all times and remen in control of the situation
Provide clear and straight forward communication
Hold person accountability for their actions
Remain consistent
Avoid being too nice or friendly.
Correct Answer : B,C,D
A. Challenge the patient at all times and remain in control of the situation:
Explanation: While maintaining a therapeutic boundary and structure is essential, challenging the patient at all times may lead to resistance or defensiveness. Collaborative and supportive approaches are often more effective than confrontational ones.
B. Provide clear and straightforward communication:
Explanation: Individuals with personality disorders may struggle with interpersonal relationships and communication. Clear and straightforward communication helps to minimize misunderstandings and establish a therapeutic environment.
C. Hold persons accountable for their actions:
Explanation: Accountability promotes responsibility and encourages individuals with personality disorders to take ownership of their behaviors. Setting clear expectations and consequences can be beneficial in fostering a sense of responsibility.
D. Remain consistent:
Explanation: Consistency in approach, rules, and expectations is crucial when working with individuals with personality disorders. It helps establish a stable and predictable environment, promoting a sense of security for the individual.
E. Avoid being too nice or friendly:
Explanation: Avoiding being too nice or friendly doesn't mean being unkind or dismissive. A balanced and professional approach, combining empathy with clear boundaries, is more beneficial. Being overly nice or friendly may blur professional boundaries and hinder therapeutic progress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "Why do you think you are being lied about and poisoned?": This question may come across as confrontational or challenging, potentially increasing the client's anxiety or defensiveness. It's important to acknowledge the client's feelings rather than questioning their beliefs directly.
B. "You are mistaken. Nobody is lying about you or trying to poison you.": This statement is dismissive and may cause the client to feel invalidated. It is crucial to acknowledge the client's feelings and experiences, even if they are not based on reality.
C. "Who is lying about you and trying to poison you?": This question may unintentionally reinforce the delusional thinking by suggesting that someone is indeed lying or trying to poison the client. It's essential to avoid validating or encouraging the delusional content.
D. "You seem to be having very frightening thoughts.": This statement acknowledges the client's emotions without directly challenging the delusional content. It shows empathy and creates an open and non-confrontational environment, allowing the client to express their feelings and experiences.
Correct Answer is C
Explanation
A. Neuroleptic malignant syndrome, treated by discontinuing antipsychotic medications: The symptoms described (uncontrollable tongue movements, stiff neck, difficulty swallowing) are more indicative of tardive dyskinesia than neuroleptic malignant syndrome. Neuroleptic malignant syndrome is characterized by hyperthermia, autonomic dysregulation, altered mental status, and generalized muscle rigidity. Treatment involves discontinuing antipsychotic medications and supportive care.
B. Agranulocytosis treated by administration of clozapine (Clozaril): Agranulocytosis is a rare but serious side effect of clozapine, not a treatment for the symptoms described. The symptoms presented are more consistent with tardive dyskinesia.
C. Tardive dyskinesia treated by discontinuing antipsychotic medication: This is the correct answer. Tardive dyskinesia is a movement disorder characterized by involuntary and abnormal movements, including tongue protrusion and facial grimacing. It can result from long-term use of antipsychotic medications, and discontinuing or reducing the dose of the antipsychotic is a primary intervention.
D. Headache treated by administration of Hydrochlorothiazide: Hydrochlorothiazide is a diuretic used to treat conditions like high blood pressure and edema, not headache or the symptoms described, which are more indicative of tardive dyskinesia.
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