NURS 218 Personal Care of Head Emergencies at Baton Rouge Community College
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Free NURS 218 Personal Care of Head Emergencies at Baton Rouge Community College Questions
The nurse is assigned to a patient diagnosed with antisocial personality disorder who frequently manipulates others. Which intervention is appropriate?
- Encourage the patient to discuss feelings of fear and inferiority
- Refer requests and questions related to care to the case manager
- Provide negative reinforcement for acting-out behavior
- Ignore, rather than confront, inappropriate behavior
Explanation
Patients with antisocial personality disorder often manipulate others and disregard the rights of others. One effective intervention is to refer the patient’s requests or questions to the case manager. This helps limit opportunities for manipulation and ensures that the care team remains consistent in enforcing boundaries and guidelines. By limiting direct interactions, the nurse can help reduce the potential for the patient to manipulate situations to their advantage.
When preparing to interview a patient diagnosed with narcissistic personality disorder, which assessment finding would the nurse anticipate?
- Charm, drama, seductiveness; seeking admiration
- Preoccupation with minute details, perfectionism
- Difficulty being alone; indecisive, submissiveness
- Grandiosity, self-importance, and a sense of entitlement
Explanation
Narcissistic personality disorder (NPD) is characterized by a pervasive pattern of grandiosity, self-importance, and a strong sense of entitlement. Individuals with NPD often believe they are superior to others and require excessive admiration. They may lack empathy and have difficulty recognizing the needs and feelings of others. The most prominent features of NPD are grandiosity and an inflated sense of their own importance, which align with the characteristics described in option D.
A nurse cares for a rape victim who was given a drink that contained flunitrazepam by an assailant. Which intervention has priority?
- Monitoring for hypotonia
- Monitoring for coma
- Monitoring for seizures
- Monitoring for respiratory depression
Explanation
Flunitrazepam, commonly known as Rohypnol, is a potent sedative-hypnotic drug that can cause severe central nervous system depression, including respiratory depression, especially when combined with alcohol or other substances. Respiratory depression is the most life-threatening side effect and should be closely monitored to ensure the patient's airway remains clear and to intervene promptly if breathing becomes impaired. Monitoring for other complications such as hypotonia, coma, and seizures is important, but respiratory depression poses the most immediate risk to life.
The nurse describes a patient as very shy and lacking in self-confidence, staying alone all day, and refusing to come out for lunch. Which term best describes this behavior?
- Avoidant
- Histrionic
- Narcissistic
- Paranoid
Explanation
Avoidant personality disorder is characterized by feelings of inadequacy, extreme sensitivity to criticism, and a strong desire for social relationships, but with a fear of rejection or failure. This leads to social withdrawal, shyness, and isolation. The described behavior of the patient — being shy, lacking self-confidence, and staying alone — fits the pattern of avoidant traits, where individuals tend to avoid social situations due to fear of negative evaluation or rejection.
A nurse in a pediatric clinic is caring for a preschool-age child who has a new diagnosis of Attention Deficit Hyperactivity Disorder (ADHD). When teaching the guardian about this disorder, which statement should the nurse include in the teaching?
- "Below-average intellectual functioning is associated with ADHD."
- "Behaviors associated with ADHD are present prior to age 3."
- "This disorder is characterized by argumentativeness."
- "Because of this disorder, your child is at an increased risk for injury."
Explanation
Children with ADHD often exhibit hyperactivity, impulsivity, and inattention, which can increase their risk for accidents and injuries. Due to their impulsive behavior and difficulty focusing, they may engage in risky behaviors without considering the potential consequences. This can lead to a higher likelihood of injuries, such as falls, cuts, or other accidents, especially in environments where supervision may be lessened.
A patient with a tracheostomy is experiencing thick, tenacious secretions and labored breathing. What is the nurse's priority intervention?
- Administer an antitussive
- Suction the tracheostomy
- Notify the health care provider
- Increase oxygen flow rate
Explanation
The priority intervention for a patient with a tracheostomy who is experiencing thick, tenacious secretions and labored breathing is to suction the tracheostomy. Suctioning helps clear the airway and remove the secretions that are obstructing breathing. This intervention is critical for maintaining airway patency and improving respiratory function. After suctioning, further actions may be necessary, such as notifying the healthcare provider or adjusting oxygen therapy, depending on the patient’s response.
A client with diagnosed early-stage laryngeal cancer is being monitored for progression. Which new symptom should prompt the nurse to notify the provider immediately as it indicates disease progression?
- Dysphagia and shortness of breath
- Mild throat dryness
- A cough occurring at night only
- Increasing hoarseness over 2 days
Explanation
Dysphagia (difficulty swallowing) and shortness of breath are concerning symptoms that may indicate progression of laryngeal cancer, particularly if the tumor is obstructing the airway or affecting the swallowing mechanism. These symptoms suggest that the cancer may be enlarging or invading structures involved in swallowing and respiration, which requires immediate medical attention. While other symptoms such as mild throat dryness, a cough at night, or hoarseness may also be related to the cancer, they are less urgent compared to symptoms affecting the patient's ability to breathe and swallow.
A nurse is providing teaching to an adolescent patient who is to begin taking atomoxetine (Strattera) for Attention Deficit Hyperactivity Disorder. The nurse should instruct the patient to monitor for which adverse effect?
- Increased appetite
- Somnolence
- Yellowing skin
- Weight gain
Explanation
Atomoxetine (Strattera) is a non-stimulant medication used to treat Attention Deficit Hyperactivity Disorder (ADHD). A rare but serious adverse effect of atomoxetine is liver damage, which can present with symptoms like yellowing of the skin (jaundice) or eyes. The nurse should instruct the patient to monitor for any signs of liver problems, such as yellowing of the skin, and report them immediately, as this could indicate liver toxicity.
A nurse is caring for a patient diagnosed with avoidant personality disorder. Which behavior could impede this patient's ability to establish close interpersonal relationships?
- Fear of rejection
- Anger and aggression
- Exploitation of others
- Lack of empathy
Explanation
A hallmark of avoidant personality disorder is an intense fear of rejection or criticism, which can prevent the individual from initiating or maintaining close interpersonal relationships. This fear leads to feelings of inadequacy, social inhibition, and avoidance of social situations, all of which can make it difficult for the person to form meaningful connections with others. They often avoid relationships to protect themselves from perceived rejection.
Which personality traits will most likely be documented by the nurse regarding a patient demonstrating characteristics of an obsessive-compulsive personality disorder?
- Dramatic speech, Impulsive
- Perfectionist, inflexible
- Suspicious, holds grudges
- Affable, generous
Explanation
Obsessive-compulsive personality disorder (OCPD) is characterized by a preoccupation with orderliness, perfectionism, and control. People with OCPD are often very detail-oriented, have high standards, and are inflexible about how things should be done. They may focus excessively on rules, order, and procedures, and may struggle to adapt to changes or to delegate tasks. This rigid, perfectionistic behavior is a hallmark of OCPD.
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