1. The nurse observes a staff member not following the plan of care for a client with an antisocial personality disorder. The nurse should:
A) confront the staff member immediately and say, 'You know that is not the treatment plan.' B) write an incident report to create a paper trail of the staff member - s failure to follow the planned program. C) ask the staff member to talk in private, and reinforce how antisocial clients try to divide staff. D) bring up the incident during the weekly conference so that this staff member is not assigned to work with antisocial persons again.
2. A client diagnosed with Borderline Personality Disorder frequently attempts to burn herself. The best intervention to facilitate behavior change is:
A) constantly observing the client to prevent self-harm. B) enlisting the client in defining and describing harmful behaviors. C) checking on the client every 15 minutes to ensure she is not engaging in harmful behavior. D) removing all items from the environment that the client could use to harm herself.
3. During a well-baby check of a 6-month-old infant, the nurse notes abrasions and petechaie of the palate. The nurse should:
A) inquire about foods the child is eating. B) ask about the possibility of sexual abuse. C) request to see the type of bottle used for feedings. D) question the parent about objects the child plays with.
4. A woman seeks assistance because she recently remembered childhood sexual abuse. The nurse should include which of the following goals for this client?
A) prosecuting the perpetrator B) managing symptoms of anxiety and fear C) determining if the memories are real D) collaborating the client - s story
5. An advance directive is written and notarized according to law in the state of Colorado. This document is legal and binding:
A) internationally. B) in the state of Colorado only. C) in the continental United States. D) in the county of origination only.
1. Right Answer: C Explanation: It is essential that the treatment program be followed exactly for clients with antisocial personality disorder because they are very manipulative and attempt to divide staff. However, confronting the staff member in front of the client enhances the division of staff. Talking with the staff member in private allows the person to develop skills to work with this client population. Psychosocial Integrity
2. Right Answer: B Explanation: The challenge when intervening with clients who might harm themselves is to maintain client safety while facilitating behavior change. Enlisting the client to identify the triggers for self-harm makes the client an active participant in treatment. Nurses are less judgmental when they understand the source of the behavior and can be sensitive to client feelings. Psychosocial Integrity
3. Right Answer: B Explanation: Generally oral sex leaves little physical evidence. Injury to the soft palate (such as bruising, abrasions, and petechaie) and pharyngeal gonorrhea are the only signs. Infants are at risk for sexual abuse. Psychosocial Integrity
4. Right Answer: B Explanation: At least 10% of victims of childhood sexual abuse have periods of complete amnesia about the abuse, followed by delayed recall. Controversial evidence suggests that people who have recovered memories have had part of those memories reconstructed by therapists. The nurses role is not to determine if the memories are real, but to help the client deal with the stress caused by the remembered abuse. Psychosocial Integrity
5. Right Answer: B Explanation: Choices 1, 3, and 4 are incorrect. Advance directive protocols and documents are defined by each state. Coordinated Care
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