Question

A highly emotional client presents at an outpatient clinic appointment wearing flamboyant attire, spiked heels. and theatrical makeup. Which of the following personality disorders should the nurse associate with the assessment data?

Answer 1

Correct Answers:

Histrionic personality disorder

Rationale :

🍊 Histrionic personality disorder is characterized by a pervasive pattern of excessive emotionality and attention-seeking behavior.

🍊 Clients may use dramatic, flamboyant, or provocative clothing and appearance as a means of attracting attention from others.

🍊 Theatrical behavior and exaggerated emotional expression are particularly characteristic of this personality disorder.

🍊 Emotions may appear rapidly shifting, exaggerated, or superficial, especially during interpersonal interactions.

🍊 Clients often feel uncomfortable when they are not the center of attention and may actively seek reassurance, approval, or recognition.

🍊 Their communication can be dramatic and impressionistic, sometimes lacking specific supporting details.

🍊 The combination of being highly emotional, flamboyantly dressed, and theatrically made up strongly reflects the attention-seeking presentation associated with this disorder.

🍊 Therefore, the assessment findings are most consistent with histrionic personality disorder.

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Answer 2

Correct Answers:

Administer an intramuscular injection of diphenhydramine.

Rationale :

🧿 Haloperidol is a high-potency first-generation antipsychotic that has a significant risk of causing extrapyramidal symptoms (EPS).

🧿 The client's stiff, fixed rotation of the head is characteristic of acute dystonia, specifically torticollis, caused by involuntary sustained muscle contractions.

🧿 Acute dystonia can develop within hours to several days after administration of a dopamine-blocking antipsychotic such as haloperidol.

🧿 Diphenhydramine has strong anticholinergic activity and is commonly used to rapidly reverse an acute dystonic reaction.

🧿 The IM route provides relatively rapid treatment and is appropriate when immediate intervention is required.

🧿 Another medication that may be used for acute dystonia is benztropine, depending on the prescription and clinical setting.

🧿 The nurse should also assess for laryngeal dystonia, difficulty swallowing, stridor, or respiratory distress, because dystonia involving the airway can become life-threatening.

🧿 Therefore, the priority intervention is to administer IM diphenhydramine to rapidly treat the haloperidol-induced acute dystonic reaction.

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Answer 3

Correct Answers:

Notify the healthcare provider and prepare to administer lorazepam intrvenously (IV).

Rationale :

🍊 The client's confusion, severe agitation, diaphoresis, visual hallucinations, hypertension, tachycardia, and fever are characteristic of delirium tremens (DTs).

🍊 Delirium tremens is the most severe form of alcohol withdrawal and commonly develops approximately 48–96 hours after cessation or significant reduction of alcohol intake.

🍊 The client's onset on the third hospital day is therefore highly consistent with the expected timing of DTs.

🍊 Severe autonomic hyperactivity, demonstrated by BP 168/102, HR 126, diaphoresis, and temperature 38.6°C, indicates a potentially life-threatening withdrawal state.

🍊 Benzodiazepines, such as lorazepam, are first-line medications because they decrease CNS hyperexcitability and help prevent withdrawal seizures and progression of delirium.

🍊 IV medication may be required in severe withdrawal because it allows rapid treatment and titration according to the client's clinical response.

🍊 The nurse should closely monitor airway, breathing, circulation, vital signs, level of consciousness, withdrawal severity, seizure activity, and response to medication while maintaining a safe environment.

🍊 Therefore, the priority is to notify the healthcare provider and prepare to administer IV lorazepam promptly because untreated delirium tremens can result in serious complications and death.

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Answer 4

Correct Answers:

Have an impromptu staff meeting to discuss consistency and limit-setting approaches.

Rationale :

✨ Clients experiencing acute severe mania can demonstrate intrusive, provocative, manipulative, argumentative, and sometimes aggressive behavior.

✨ The client's behavior has already caused staff members to become defensive and fatigued, which can interfere with therapeutic responses and consistent care.

✨ A brief staff meeting allows team members to establish clear, consistent behavioral limits and agree on how those limits will be enforced.

✨ Consistency prevents the client from successfully splitting staff members, manipulating differences in responses, or escalating conflicts between caregivers.

✨ Staff should use brief, calm, matter-of-fact communication because lengthy explanations and arguments can further stimulate a severely manic client.

✨ Limits should focus on specific behaviors and consequences rather than criticizing or punishing the client.

✨ Coordinating the team's approach also allows staff to recognize their own emotional responses and prevent countertransference, frustration, or inconsistent limit setting from affecting care.

✨ Therefore, an immediate staff conference to establish consistent limit-setting approaches is the best intervention.

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Answer 5

Correct Answers:

"I should set the unit's rules and expectations to prevent manipulation."

Rationale :

✳️ Clients with certain personality disorders, particularly antisocial and borderline personality disorders, may demonstrate manipulation, testing of limits, or staff splitting.

✳️ Establishing clear rules, expectations, and behavioral boundaries helps create a structured and predictable therapeutic environment.

✳️ Limits should be communicated in a calm, direct, neutral, and nonpunitive manner so that expectations are clearly understood.

✳️ All staff members should maintain a consistent approach, because inconsistent responses can reinforce manipulation or allow the client to play staff members against one another.

✳️ Consequences for inappropriate behavior should be realistic, clearly stated, and consistently enforced.

✳️ The nurse should focus limits on the client's behavior rather than personality, avoiding criticism, arguments, or power struggles.

✳️ Consistent boundaries promote accountability and appropriate interpersonal functioning while protecting the therapeutic milieu.

✳️ Therefore, establishing unit rules and expectations to limit manipulation demonstrates an appropriate understanding of nursing care for clients with personality disorders.

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Answer 6

Correct Answers:

Binge eating, purging, normal weight, and hypokalemia

Rationale :

🔷 Bulimia nervosa is characterized by recurrent episodes of binge eating followed by inappropriate compensatory behaviors intended to prevent weight gain.

🔷 Compensatory behaviors commonly include self-induced vomiting, misuse of laxatives or diuretics, fasting, or excessive exercise.

🔷 Unlike many clients with anorexia nervosa, clients with bulimia are often normal weight or may have weight fluctuations, making the disorder less visibly apparent.

🔷 Repeated vomiting causes loss of gastric fluids and electrolytes, particularly potassium and chloride.

🔷 This electrolyte loss can produce hypokalemia, which increases the risk of dangerous cardiac dysrhythmias.

🔷 Vomiting can also produce metabolic alkalosis, dehydration, weakness, and orthostatic hypotension.

🔷 Other characteristic findings include dental enamel erosion, parotid gland enlargement, sore throat, and calluses on the knuckles (Russell sign) from inducing vomiting.

🔷 Therefore, binge eating, purging, normal weight, and hypokalemia represent the findings most consistent with bulimia nervosa.

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Answer 7

Correct Answers:

The client is expressing an obsession with germs.

Rationale :

🔷 Obsessive-compulsive disorder (OCD) is characterized by obsessions, compulsions, or both that cause significant distress or interfere with functioning.

🔷 An obsession is a recurrent, persistent, intrusive, and unwanted thought, urge, or image that causes anxiety or distress.

🔷 The client's inability to stop thinking about potentially life-threatening germs represents a persistent intrusive thought rather than an observable repetitive behavior.

🔷 Fear of contamination or germs is one of the common obsessional themes experienced by clients with OCD.

🔷 Clients often recognize that these thoughts are excessive or unwanted but experience substantial difficulty controlling or suppressing them.

🔷 Obsessions may lead to compulsions, such as excessive handwashing, cleaning, checking, or avoidance, performed to reduce the anxiety generated by the intrusive thoughts.

🔷 Accurate documentation distinguishes an obsession, which is a thought, from a compulsion, which is a repetitive behavior or mental act.

🔷 Therefore, the nurse should document that the client is expressing an obsession with germs.

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Answer 8

Correct Answers:

Administer naloxone as prescribed and monitor respiratory status.

Rationale :

🚑 The combination of unresponsiveness, pinpoint pupils, and severe respiratory depression is classic for an opioid overdose, such as heroin toxicity.

🚑 A respiratory rate of 6 breaths/min indicates profound respiratory depression and places the client at immediate risk for hypoxemia, respiratory arrest, and death.

🚑 Naloxone is a competitive opioid receptor antagonist that rapidly reverses opioid-induced respiratory and central nervous system depression.

🚑 Naloxone should be administered promptly while the nurse simultaneously supports airway and ventilation, including oxygen and assisted ventilation when needed.

🚑 Improvement is typically demonstrated by an increased respiratory rate, improved level of consciousness, and better oxygenation.

🚑 Continued respiratory monitoring is essential because naloxone's duration of action may be shorter than that of the opioid, allowing respiratory depression to recur after the initial response.

🚑 Additional naloxone doses or a continuous infusion may be required depending on the client's clinical response and the opioid involved.

🚑 Therefore, among the options provided, administering naloxone and closely monitoring respiratory status is the priority intervention for suspected heroin overdose.

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Answer 9

Correct Answers:

Agranulocytosis

Rationale :

🩺 Clozapine can cause severe neutropenia or agranulocytosis, which is a potentially fatal reduction in infection-fighting white blood cells. 🩺 Clients taking clozapine require regular monitoring of the absolute neutrophil count (ANC) according to current treatment requirements and clinical guidance. 🩺 A dangerously low neutrophil count greatly increases the risk for serious and potentially life-threatening infection. 🩺 The client should promptly report fever, sore throat, chills, malaise, or other signs of infection. 🩺 Clozapine may need to be interrupted or discontinued if the ANC falls below specified safety thresholds. 🩺 This adverse effect is especially important because early infection symptoms may be the first clue that severe neutropenia has developed. 🩺 Other serious clozapine risks include myocarditis, seizures, severe constipation or ileus, and cardiometabolic complications, but agranulocytosis is the classic potentially fatal effect tested in this question. 🩺 Therefore, teaching about agranulocytosis and infection warning signs is essential when a client begins clozapine.

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Answer 10

Correct Answers:

Hold the next dose of lithium and notify the healthcare provider.

Rationale :

🩺 Lithium has a narrow therapeutic index, meaning the difference between a therapeutic and toxic serum concentration is relatively small. 🩺 Nausea and worsening hand tremors can be early manifestations of lithium toxicity, particularly when they represent new or increasing symptoms. 🩺 Increased thirst can occur during lithium therapy and may reflect lithium-related effects on renal water handling. 🩺 The combination of these findings warrants evaluation rather than automatically assuming that all symptoms are harmless expected effects. 🩺 The nurse should hold the next lithium dose and notify the healthcare provider so the client can be assessed and a serum lithium concentration obtained as indicated. 🩺 Additional assessments should include hydration status, renal function, sodium level, medication interactions, and recent episodes of vomiting, diarrhea, excessive sweating, or reduced fluid intake. 🩺 More severe toxicity can progress to coarse tremors, persistent gastrointestinal symptoms, confusion, ataxia, dysarthria, seizures, and potentially life-threatening neurologic complications. 🩺 Therefore, holding lithium and promptly notifying the healthcare provider is the safest action among the options.

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QLexNursing

1 :
A highly emotional client presents at an outpatient clinic appointment wearing flamboyant attire, spiked heels. and theatrical makeup. Which of the following personality disorders should the nurse associate with the assessment data?

2 :
An acutely violent client diagnosed with schizophrenia receives an emergency dose of haloperidol. Two hours later, the nurse notices the client's head rotated to one side in a stiffly-fixed position. Which primary intervention by the nurse is best indicated?

4 :
A client is experiencing acute, severe mania. The client has joked. manipulated, insulted, and fought with others all morning. Staff members are feeling defensive and fatigued. Which is the best action at this time?

5 :
A newly-graduated nurse is working in a mental health facility. Which of the following statements made by the nurse to a coworker indicates a good understanding of caring for a client with a personality disorder?

6 :
A client has been hospitalized on the psychiatric unit with a diagnosis of bulimia nervosa. Which of the following symptoms would be consistent with this diagnosis?

7 :
A client diagnosed with obsessive-compulsive disorder reports to the nurse that they can't stop thinking about all the potentially life-threatening germs in the environment. Which is an accurate way for the nurse to document this symptom?

8 :
A client is brought to the emergency department by emergency medical services after being found unresponsive with shallow respirations. The client has pinpoint pupils. a respiratory rate of 6 breaths per minute. and is suspected of a heroin overdose. What is the nurse's priority intervention?

9 :
A client with schizophrenia has recently begun a new medication, clozapine. Which is a potential fatal side effect that should be included in the teaching plan?

10 :
A nurse is caring for a client with bipolar disorder who has been taking lithium carbonate for the past 6 months. During the morning assessment, the client reports nausea. hand tremors, and increased thirst. Which of the following is the most appropriate action by the nurse?

QLexNursing

1 : A highly emotional client presents at an outpatient clinic appointment wearing flamboyant attire, spiked heels. and theatrical makeup. Which of the following personality disorders should the nurse associate with the assessment data?

2 : An acutely violent client diagnosed with schizophrenia receives an emergency dose of haloperidol. Two hours later, the nurse notices the client's head rotated to one side in a stiffly-fixed position. Which primary intervention by the nurse is best indicated?

4 : A client is experiencing acute, severe mania. The client has joked. manipulated, insulted, and fought with others all morning. Staff members are feeling defensive and fatigued. Which is the best action at this time?

5 : A newly-graduated nurse is working in a mental health facility. Which of the following statements made by the nurse to a coworker indicates a good understanding of caring for a client with a personality disorder?

6 : A client has been hospitalized on the psychiatric unit with a diagnosis of bulimia nervosa. Which of the following symptoms would be consistent with this diagnosis?

7 : A client diagnosed with obsessive-compulsive disorder reports to the nurse that they can't stop thinking about all the potentially life-threatening germs in the environment. Which is an accurate way for the nurse to document this symptom?

8 : A client is brought to the emergency department by emergency medical services after being found unresponsive with shallow respirations. The client has pinpoint pupils. a respiratory rate of 6 breaths per minute. and is suspected of a heroin overdose. What is the nurse's priority intervention?

9 : A client with schizophrenia has recently begun a new medication, clozapine. Which is a potential fatal side effect that should be included in the teaching plan?

10 : A nurse is caring for a client with bipolar disorder who has been taking lithium carbonate for the past 6 months. During the morning assessment, the client reports nausea. hand tremors, and increased thirst. Which of the following is the most appropriate action by the nurse?

1 :
A highly emotional client presents at an outpatient clinic appointment wearing flamboyant attire, spiked heels. and theatrical makeup. Which of the following personality disorders should the nurse associate with the assessment data?

2 :
An acutely violent client diagnosed with schizophrenia receives an emergency dose of haloperidol. Two hours later, the nurse notices the client's head rotated to one side in a stiffly-fixed position. Which primary intervention by the nurse is best indicated?

4 :
A client is experiencing acute, severe mania. The client has joked. manipulated, insulted, and fought with others all morning. Staff members are feeling defensive and fatigued. Which is the best action at this time?

5 :
A newly-graduated nurse is working in a mental health facility. Which of the following statements made by the nurse to a coworker indicates a good understanding of caring for a client with a personality disorder?

6 :
A client has been hospitalized on the psychiatric unit with a diagnosis of bulimia nervosa. Which of the following symptoms would be consistent with this diagnosis?

7 :
A client diagnosed with obsessive-compulsive disorder reports to the nurse that they can't stop thinking about all the potentially life-threatening germs in the environment. Which is an accurate way for the nurse to document this symptom?

8 :
A client is brought to the emergency department by emergency medical services after being found unresponsive with shallow respirations. The client has pinpoint pupils. a respiratory rate of 6 breaths per minute. and is suspected of a heroin overdose. What is the nurse's priority intervention?

9 :
A client with schizophrenia has recently begun a new medication, clozapine. Which is a potential fatal side effect that should be included in the teaching plan?

10 :
A nurse is caring for a client with bipolar disorder who has been taking lithium carbonate for the past 6 months. During the morning assessment, the client reports nausea. hand tremors, and increased thirst. Which of the following is the most appropriate action by the nurse?