Question

A nurse is caring for a client who has antisocial personality disorder and reports planning to hurt their partner upon discharge. Which of the following actions should the nurse take?

Answer 1

Correct Answers:

Report the information to local authorities.

Rationale :

🔴 When a client threatens to harm someone, the nurse has a legal and ethical obligation to break confidentiality and report the threat to local authorities under the duty to warn and protect doctrine.

🔴 Clients with antisocial personality disorder may display impulsivity and disregard for the safety of others, which increases the risk of violence.

🔴 Reporting is essential to prevent harm, ensure public safety, and initiate protective measures.

🔴 The nurse should also document the threat and notify the provider, but reporting is the priority action.

🔴 Failing to act could result in legal consequences for the facility and the nurse.

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Answer 2

Correct Answers:

Plan a menu with the client.

Rationale :

🟢 Clients with binge eating disorder benefit from structured meal planning to reduce impulsive eating behaviors.

🟢 Involving the client in menu planning promotes autonomy, reduces anxiety around food, and builds healthy habits.

🟢 This collaborative approach enhances nutritional balance and decreases the likelihood of binge episodes.

🟢 Unlike bulimia nervosa, these clients do not purge, so care focuses more on meal regularity and emotional support.

🟢 It also facilitates trust-building between client and provider.

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Answer 3

Correct Answers:

"Snap a rubber band on your wrist when you think about checking the locks."

Rationale :

🟡 Thought stopping is a cognitive-behavioral technique used to interrupt obsessive thoughts with a physical or verbal cue.

🟡 Snapping a rubber band provides a mild aversive stimulus that helps shift the client’s focus from the compulsion.

🟡 This method encourages awareness of thought patterns and promotes behavioral control.

🟡 It is especially useful in obsessive-compulsive disorder (OCD) where rituals interfere with daily functioning.

🟡 The goal is to eventually reduce and eliminate the compulsive behavior by replacing it with a healthier response.

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Answer 4

Correct Answers:

Improvement in manifestations of depression

Rationale :

🔵 Electroconvulsive therapy (ECT) is most commonly used to treat severe depression, especially when medications are ineffective.

🔵 Clinical improvement may include enhanced mood, energy, sleep, and appetite after a series of treatments.

🔵 ECT alters neurotransmitter activity, helping to relieve depressive symptoms in treatment-resistant cases.

🔵 It is not used to treat phobias, seizures, or panic attacks, so improvement in depression is the intended outcome.

🔵 Nurses monitor mood and affect over time to evaluate therapeutic response.

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Answer 5

Correct Answers:

Hypertension

Rationale :

🟣 Cocaine is a potent central nervous system stimulant that causes increased norepinephrine and dopamine levels.

🟣 This leads to sympathetic nervous system stimulation, manifesting as hypertension, tachycardia, dilated pupils, and hyperactivity.

🟣 Other signs include euphoria, restlessness, and risk of myocardial infarction or stroke.

🟣 The nurse must assess for cardiovascular instability and monitor for complications of overdose or toxicity.

🟣 Cocaine withdrawal may follow with symptoms of fatigue and depression, but acute use causes elevated vital signs.

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Answer 6

Correct Answers:

"Have you been thinking about harming yourself?"

Rationale :

⚫ When a client expresses hopelessness, it is a red flag for suicidal ideation and should be assessed immediately.

⚫ Asking directly about self-harm is a therapeutic and responsible approach, not one that increases risk.

⚫ Early identification allows the nurse to initiate appropriate interventions such as a safety plan or psychiatric referral.

⚫ This question opens up space for the client to talk about distress without judgment.

⚫ Suicide prevention requires honest, clear communication and rapid evaluation.

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Answer 7

Correct Answers:

"You sound upset about today's session."

Rationale :

🟤 This response uses therapeutic communication, specifically reflection of feeling, to validate the client’s emotional state.

🟤 It acknowledges the client’s distress without making assumptions or escalating the situation.

🟤 This allows the client to process emotions and opens the door to further discussion.

🟤 It’s important in group settings to ensure clients feel safe, heard, and respected.

🟤 Nurses should avoid agreeing with or confronting other clients directly but focus on the reporting client’s experience.

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Answer 8

Correct Answers:

10

Rationale :

🟠 Ordered dose per day: 40 mg, divided into 2 doses = 20 mg per dose.

🟠 Available concentration: 10 mg / 5 mL

🟠 Use ratio calculation:

(10 mg / 5 mL) = (20 mg / X mL)

🟠 Cross-multiply:

10X = 100 →

X = 10 mL per dose

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Answer 9

Correct Answers:

Provide written information about the client's treatment plan.

Rationale :

🟡 Clients with paranoid personality disorder are often suspicious, mistrustful, and hypervigilant.

🟡 Providing written materials helps reduce anxiety and builds trust, as the client can review facts independently.

🟡 Verbal explanations may be misinterpreted as manipulation or deceit, especially in early stages of treatment.

🟡 The nurse should avoid behaviors that may seem secretive or controlling, and provide clear, consistent communication.

🟡 Building rapport requires a non-threatening, fact-based approach with clients who distrust others.

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Answer 10

Correct Answers:

"Therapy is often scheduled during my daily meditation time."

Rationale :

🟢 This statement reflects a conflict between spiritual practice and treatment, which is a common sign of spiritual distress.

🟢 Clients experiencing spiritual distress may feel disconnected, frustrated, or conflicted when their beliefs are disrupted.

🟢 Such distress can affect coping ability, healing, and adherence to care plans.

🟢 The nurse should explore the issue further to develop a plan that honors the client’s spiritual needs while ensuring appropriate care.

🟢 Addressing spirituality is a key component of holistic nursing care.

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QLexNursing

1 :
A nurse is caring for a client who has antisocial personality disorder and reports planning to hurt their partner upon discharge. Which of the following actions should the nurse take?

2 :
A nurse is caring for a client who has a binge eating disorder. Which of the following actions should the nurse take?

3 :
A nurse is providing behavioral therapy for a client who has obsessive-compulsive disorder. The client repeatedly checks that the doors are locked at night. Which of the following instructions should the nurse give the client when using thought stopping technique?

4 :
A nurse is assessing a client who has been receiving electroconvulsive therapy. Which of the following findings indicates the treatment is effective?

5 :
A nurse in an emergency department is assessing a client who reports recently using cocaine. Which of the following clinical manifestations should the nurse expect?

6 :
A nurse is caring for a client who states, "Things will never work out." Which of the following responses should the nurse make?

7 :
A nurse is talking to a client following a group therapy session. The client tells the nurse that one of the other clients in the group made an Inappropriate comment. Which of the following responses should the nurse make?

9 :
A nurse is developing a plan of care for a client who has paranoid personality disorder. Which of the following actions should the nurse include in the plan?

10 :
A nurse is assessing the spiritual beliefs of a client. Which of the following client statements indicates spiritual distress?

QLexNursing

1 : A nurse is caring for a client who has antisocial personality disorder and reports planning to hurt their partner upon discharge. Which of the following actions should the nurse take?

2 : A nurse is caring for a client who has a binge eating disorder. Which of the following actions should the nurse take?

3 : A nurse is providing behavioral therapy for a client who has obsessive-compulsive disorder. The client repeatedly checks that the doors are locked at night. Which of the following instructions should the nurse give the client when using thought stopping technique?

4 : A nurse is assessing a client who has been receiving electroconvulsive therapy. Which of the following findings indicates the treatment is effective?

5 : A nurse in an emergency department is assessing a client who reports recently using cocaine. Which of the following clinical manifestations should the nurse expect?

6 : A nurse is caring for a client who states, "Things will never work out." Which of the following responses should the nurse make?

7 : A nurse is talking to a client following a group therapy session. The client tells the nurse that one of the other clients in the group made an Inappropriate comment. Which of the following responses should the nurse make?

9 : A nurse is developing a plan of care for a client who has paranoid personality disorder. Which of the following actions should the nurse include in the plan?

10 : A nurse is assessing the spiritual beliefs of a client. Which of the following client statements indicates spiritual distress?

1 :
A nurse is caring for a client who has antisocial personality disorder and reports planning to hurt their partner upon discharge. Which of the following actions should the nurse take?

2 :
A nurse is caring for a client who has a binge eating disorder. Which of the following actions should the nurse take?

3 :
A nurse is providing behavioral therapy for a client who has obsessive-compulsive disorder. The client repeatedly checks that the doors are locked at night. Which of the following instructions should the nurse give the client when using thought stopping technique?

4 :
A nurse is assessing a client who has been receiving electroconvulsive therapy. Which of the following findings indicates the treatment is effective?

5 :
A nurse in an emergency department is assessing a client who reports recently using cocaine. Which of the following clinical manifestations should the nurse expect?

6 :
A nurse is caring for a client who states, "Things will never work out." Which of the following responses should the nurse make?

7 :
A nurse is talking to a client following a group therapy session. The client tells the nurse that one of the other clients in the group made an Inappropriate comment. Which of the following responses should the nurse make?

9 :
A nurse is developing a plan of care for a client who has paranoid personality disorder. Which of the following actions should the nurse include in the plan?

10 :
A nurse is assessing the spiritual beliefs of a client. Which of the following client statements indicates spiritual distress?