Complete Solutions 2024.
A nurse is establishing a therapeutic relationship with a client who has antisocial personality disorder.
Which of the following strategies should the nurse use when communicating with this client?
Behave in a friendly manner toward the client
Set realistic limits on the client's behavior
Show respect for the client's need for isolation
Act as a role model for assertiveness - Answer Set realistic limits on the clients behavior
Clients who have antisocial personality disorder can seem to be in control of their behavior, but are
manipulative and impulsive and can suddenly become aggressive and assaultive. The nurse should
establish clear limits on specific aggressive and demanding behaviors.
A nurse is caring for a child who has conducted disorder and is behaving in a destructive manner,
throwing objects, and kicking others. Which of the following therapeutic nursing interventions is the
priority?
Encourage expression of feelings
Support the child's attendance at an assertiveness training group
Assist the child to perform relaxation breathing
Reduce environmental stimuli - Answer Reduce environmental stimuli
,The greatest risk to the child and others is harm. Therefore, the nurse's priority intervention is to reduce
environmental stimuli in an attempt to de-escalate the behavior and prevent injury.
A nurse in a community health center is working with a group of clients who have post-traumatic stress
disorder. Which of the following interventions should the nurse include to reduce anxiety among the
group members?
Response prevention
Guided imagery
Aversion therapy
Light therapy - Answer Guided imagery
Guided imagery involves assisting the client to imagine a restful and safe place. This method is effective
in reducing anxiety in clients who have post-traumatic stress disorder.
A nurse is performing a cognitive assessment to distinguish delirium from dementia in a client whose
family reports episodes of confusion. Which of the following assessment findings supports the nurse's
suspicion of delirium?
Slow onset
Aphasia
Confabulation
Easily distracted - Answer Easily distracted
, Extreme distractibility is a hallmark manifestation of delirium.
A nurse is caring for an older adult client who begins to cry and states, "I knew God would punish me and
I deserve this horrible sickness!" Which of the following responses should the nurse make?
"Why do you think you deserve this punishment?"
"Don't worry about being punished by God."
"Let's talk about what is upsetting you."
"You shouldn't say things that will upset you so much." - Answer "Let's talk about what is upsetting
you."
The nurse is acknowledging the client's concerns and is showing a desire to understand what the client is
thinking and feeling.
A client who has a recent diagnosis of bipolar disorder is placed in a room with a client who has severe
depression. The client who has depression reports to the nurse, "My roommate never sleeps and keeps
me up, too." Which of the following actions should the nurse take?
Move the client who has bipolar disorder to a private room
Administer sleep medication to the client who has bipolar disorder.
Move the client who has severe depression to a private room.
Administer sleep medication to the client who has severe depression. - Answer Move the client who
has bipolar disorder to a private room.