Difficulty: Medium
Average Score: 68%
Simulated
Passage / Scenario
Vital SignsBlood pressure: 112/68 mm Hg
Temperature: 37┬░ C (98.6┬░ F)
Heart rate: 64/min
Respiratory rate: 12/min
Oxygen saturation: 98% on room air
Medical History
A 19-year-old female client presents to the clinic accompanied by her parents. The parents indicate they "have to do something or she is going to end up in jail - we cannot believe a thing she tells us.ÔÇØ The client is disinterested, standing with arms crossed, and not answering questions when addressed. Her parents indicate she ÔÇ£can be very nice to be around, but when denied something she wants, she becomes aggressive and abusive.ÔÇØ Parents report impulsivity and that the client does not show remorse for her actions. According to her parents, ÔÇ£she is reckless and irresponsible.ÔÇØ The parents indicate this type of behavior started around age 13 and has recently become more frequent. The client states, ÔÇ£I can do what I want. Nobody is going to tell me what to do.ÔÇØ
A nurse is caring for a client. Exhibits:Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the clientÔÇÖs progress.
Correct answer
B, A&E, C&E
Rationale
The correct answer is B, A&E, C&E. The client is most likely experiencing a personality disorder, which falls under the category of mental health conditions. The nurse should address this by first assessing the specific personality disorder the client may have (choice A) to tailor the care plan accordingly. Next, the nurse should maintain a low-stimuli environment and establish clear boundaries (choices A) to help manage the client's behaviors and promote a sense of safety. The nurse should monitor daily weight and proactive behavior (choice C) to assess physical and psychological well-being, and monitor aggressive and violent behavior and deceitfulness (choice E) to evaluate progress and potential risks. The other choices are incorrect as they do not address the specific mental health condition or appropriate actions and parameters for managing and assessing the client's condition effectively.