The nurse working on an inpatient psychiatric unit admits a ...

[jlmhmf]

The nurse working on an inpatient psychiatric unit admits a client diagnosed with antisocial personality disorder.
 
  After obtaining admission data from the client, the nurse plans care to include: (Select all that apply.)
  Standard Text: Select all that apply.
  1. Careful monitoring of the new client's interaction with others on the unit.
  2. Consistency in staff assigned to care for this client.
  3. Strict limit-setting, with the rules carefully explained and written for the client.
  4. Involvement in group therapy.
  5. Encouraging socialization with other clients on the unit

Question 2

The nurse is preparing a client for surgery who will leave for the operating room in 60 minutes. Prior to administering the preoperative medication, the nurse instructs the client to:
 
  1. Void.
  2. Bathe.
  3. Review the signed preoperative consent.
  4. Deep-breathe and cough.

[eliasc0401]

Answer to Question 1

1,2,3
Rationale: Clients with antisocial personality disorder often are manipulative, so it is important to carefully monitor interactions with other clients, because they can be very upsetting to the unit as they manipulate other clients to do their bidding. There should be consistency in staff assignments because the client often will play one staff member against another. Further, consistent staffing is most effective in setting limits and consistently maintaining them.

Answer to Question 2

1
Rationale: Prior to administering the preoperative medication, the nurse should instruct the client to empty the bladder. The bath should have been performed before the time for preoperative medication is due. There is no need for the client to review the operative consent if it has already been signed, and exercises begin after surgery.