A nurse in an acute mental health facility is
creating a plan of care for a new client who has a
co
,A nurse in an acute mental health facility is creating a plan of care for a new client who has a co-
occurring histrionic personality disorder. Which of the following is the priority intervention for the
nurse to make?
A. Promote appropriate behavior during group therapy sessions.
B. Encourage client input in the treatment plan.
C. Communicate with the client using concrete language.
D. Demonstrate assertive behavior. - Answer A. Promote appropriate behavior during group therapy
sessions.
Rationale: Managing the client's behavior within the group is the priority intervention for the client
who has histrionic personality disorder because these clients display extreme attention-seeking
behaviors and are often impulsive, which can be extremely disruptive in a group setting with other
members.
A nurse is reviewing the history and physical of an adolescent client who has conduct disorder. Which
of the following is an expected finding?
A. Death of client's father two months ago
B. Experiences frequent facial tics
C. Suspended from school several times in the past year
D. Adheres strictly to routines - Answer C. Suspended from school several times in the past year
Rationale: Conduct disorder is an impulse-control disorder which includes a long-term pattern of
violating the rights of others and performing violent or hostile acts.
A nurse is planning discharge for a client who has a co-occurring borderline personality disorder. Which
of the following interventions should be included for this client?
A. Dialectical behavior therapy
B. Behavioral contract
C. Bibliotherapy
D. Safety plan - Answer A. Dialectical behavior therapy
Rationale: Dialectical behavior therapy is appropriate for the treatment of clients with borderline
personality disorder and is often a part of the discharge plan.
A nurse is planning care for a client who has dependent personality disorder. Which of the following
actions should the nurse plan to take?
A. Monitor the client closely to prevent self-mutilation.
B. Set limits to prevent exploitation of other clients.
C. Discourage flamboyant or seductive behaviors.
D. Give positive feedback when client is assertive with staff or clients. - Answer D. Give positive
feedback when client is assertive with staff or clients.
Rationale: The client who has dependent personality disorder has great difficulty demonstrating
assertive behavior and commonly relies on others to make decisions. The nurse should encourage the
client to be more assertive and independent.
A nurse is reviewing the medical record of a client who performs self-injury. Which of the following
information should the nurse identify as placing the client at risk for self- harm behaviors?
, A. The client has a co-occurring borderline personality disorder.
B. The client has a parent who has dependent personality disorder.
C. The client has a history of bulimia nervosa.
D. The client has a diagnosis of anti-social personality disorder. - Answer A. The client has a co-
occurring borderline personality disorder.
Rationale: A diagnosis of borderline personality disorder is associated with an increased risk for self-
harm.
A nurse is caring for a client who has schizophrenia and tells the nurse, "They lie about me all the time
and they are trying to poison my food." Which of the following statements should the nurse make?
A. "You are mistaken. Nobody is lying about you or trying to poison you."
B. "You seem to be having very frightening thoughts."
C. "Why do you think you are being lied about and poisoned?"
D. "Who is lying about you and trying to poison you?" - Answer B. "You seem to be having very
frightening thoughts."
Rationale: When responding to a client who is delusional, the nurse should avoid making statements
that directly confront or affirm the client's delusional beliefs. Instead of responding literally to the
client's words, the nurse should respond to the feelings that the client is attempting to communicate. By
doing this, the nurse is shifting the focus from the delusional beliefs, which are not real, to the client's
fear, which is real.
A nurse is conducting a group therapy session for several clients. The group is laughing at a joke one of
the clients told, when a client who is schizophrenic jumps up and runs out of the room yelling, "You are
all making fun of me!" The nurse should identify this behavior as which of the following characteristics
of schizophrenia?
A. Magical thinking
B. Delusions of grandeur
C. Ideas of reference
D. Looseness of association - Answer C. Ideas of reference
Rationale: When ideas of reference are present, the client believes all events, situations, or interactions
are directly related to him.
A nurse is providing teaching for a client who has schizophrenia and a new prescription for
fluphenazine. Which of the following information should the nurse provide?
A. "This medication might turn urine your orange."
B. "Sleepiness should subside within a week."
C. "Stop the medication if hypotension occurs."
D. "A low-grade fever is expected with first doses." - Answer B. "Sleepiness should subside within a
week."
Rationale: The nurse should inform the client that fluphenazine, like other first- generation
antipsychotics, may cause sedation with early treatment, but should subside within a week or so.
creating a plan of care for a new client who has a
co
,A nurse in an acute mental health facility is creating a plan of care for a new client who has a co-
occurring histrionic personality disorder. Which of the following is the priority intervention for the
nurse to make?
A. Promote appropriate behavior during group therapy sessions.
B. Encourage client input in the treatment plan.
C. Communicate with the client using concrete language.
D. Demonstrate assertive behavior. - Answer A. Promote appropriate behavior during group therapy
sessions.
Rationale: Managing the client's behavior within the group is the priority intervention for the client
who has histrionic personality disorder because these clients display extreme attention-seeking
behaviors and are often impulsive, which can be extremely disruptive in a group setting with other
members.
A nurse is reviewing the history and physical of an adolescent client who has conduct disorder. Which
of the following is an expected finding?
A. Death of client's father two months ago
B. Experiences frequent facial tics
C. Suspended from school several times in the past year
D. Adheres strictly to routines - Answer C. Suspended from school several times in the past year
Rationale: Conduct disorder is an impulse-control disorder which includes a long-term pattern of
violating the rights of others and performing violent or hostile acts.
A nurse is planning discharge for a client who has a co-occurring borderline personality disorder. Which
of the following interventions should be included for this client?
A. Dialectical behavior therapy
B. Behavioral contract
C. Bibliotherapy
D. Safety plan - Answer A. Dialectical behavior therapy
Rationale: Dialectical behavior therapy is appropriate for the treatment of clients with borderline
personality disorder and is often a part of the discharge plan.
A nurse is planning care for a client who has dependent personality disorder. Which of the following
actions should the nurse plan to take?
A. Monitor the client closely to prevent self-mutilation.
B. Set limits to prevent exploitation of other clients.
C. Discourage flamboyant or seductive behaviors.
D. Give positive feedback when client is assertive with staff or clients. - Answer D. Give positive
feedback when client is assertive with staff or clients.
Rationale: The client who has dependent personality disorder has great difficulty demonstrating
assertive behavior and commonly relies on others to make decisions. The nurse should encourage the
client to be more assertive and independent.
A nurse is reviewing the medical record of a client who performs self-injury. Which of the following
information should the nurse identify as placing the client at risk for self- harm behaviors?
, A. The client has a co-occurring borderline personality disorder.
B. The client has a parent who has dependent personality disorder.
C. The client has a history of bulimia nervosa.
D. The client has a diagnosis of anti-social personality disorder. - Answer A. The client has a co-
occurring borderline personality disorder.
Rationale: A diagnosis of borderline personality disorder is associated with an increased risk for self-
harm.
A nurse is caring for a client who has schizophrenia and tells the nurse, "They lie about me all the time
and they are trying to poison my food." Which of the following statements should the nurse make?
A. "You are mistaken. Nobody is lying about you or trying to poison you."
B. "You seem to be having very frightening thoughts."
C. "Why do you think you are being lied about and poisoned?"
D. "Who is lying about you and trying to poison you?" - Answer B. "You seem to be having very
frightening thoughts."
Rationale: When responding to a client who is delusional, the nurse should avoid making statements
that directly confront or affirm the client's delusional beliefs. Instead of responding literally to the
client's words, the nurse should respond to the feelings that the client is attempting to communicate. By
doing this, the nurse is shifting the focus from the delusional beliefs, which are not real, to the client's
fear, which is real.
A nurse is conducting a group therapy session for several clients. The group is laughing at a joke one of
the clients told, when a client who is schizophrenic jumps up and runs out of the room yelling, "You are
all making fun of me!" The nurse should identify this behavior as which of the following characteristics
of schizophrenia?
A. Magical thinking
B. Delusions of grandeur
C. Ideas of reference
D. Looseness of association - Answer C. Ideas of reference
Rationale: When ideas of reference are present, the client believes all events, situations, or interactions
are directly related to him.
A nurse is providing teaching for a client who has schizophrenia and a new prescription for
fluphenazine. Which of the following information should the nurse provide?
A. "This medication might turn urine your orange."
B. "Sleepiness should subside within a week."
C. "Stop the medication if hypotension occurs."
D. "A low-grade fever is expected with first doses." - Answer B. "Sleepiness should subside within a
week."
Rationale: The nurse should inform the client that fluphenazine, like other first- generation
antipsychotics, may cause sedation with early treatment, but should subside within a week or so.
