Which underlying cause of this client's personality disorder should the nurse recognize?

Correct Answer: B

Rationale: The correct answer is B because personality disorders often stem from maladaptive patterns of behavior learned in childhood. In this case, the client received exclusive nurturance from one source, leading to dependency and discouragement of independent behaviors. This can contribute to the development of a personality disorder characterized by reliance on others for validation and support. Choices A, C, and D all involve a mix of multiple sources of nurturance and encouragement or discouragement of independent behaviors, which do not align with the typical underlying cause of a personality disorder rooted in dependency on a single source of nurturance.

Correct Answer: A

Rationale: The correct answer is A because providing external limits on client behavior helps establish boundaries and consequences for inappropriate actions, promoting accountability and potentially reducing guilt-inducing behaviors. This intervention can guide the client towards more appropriate behaviors and reinforce the importance of adhering to set limits. Explanation of why the other choices are incorrect: B: Foster discussions of rationales for behavioral change - While discussing rationales for behavioral change can be beneficial, it may not directly address the lack of guilt feelings in the client. C: Implement interventions consistently by only one staff member - Consistency in interventions is important, but limiting interventions to one staff member may not be sufficient to address the underlying lack of guilt feelings. D: Encourage the client to involve self in care - Encouraging client involvement in care is important for empowerment but may not directly address the lack of guilt feelings.

Correct Answer: B

Rationale: The correct answer is B because it provides an empathetic and accurate response. It reassures the mother that her parenting did not cause autism, highlighting research on brain abnormalities as the primary factor. This response promotes understanding and reduces guilt. Option A is incorrect as it only mentions one potential factor (fetal alcohol syndrome) and does not address the broader causes of ASD. Option C is incorrect as it wrongly implies that the mother's role is greater than the father’s in causing ASD, which is not supported by research. Option D is incorrect as it wrongly suggests that lack of early bonding or breastfeeding might cause autism, which is not substantiated by scientific evidence.

Correct Answer: C

Rationale: The correct answer is C because holding the client's head steady and applying a helmet is the most appropriate intervention to prevent injury while addressing the head-banging behavior. Restraints (choice A) are not recommended as they can escalate aggression. Sedating the client (choice B) may have adverse effects. Distracting the client (choice D) does not address the safety concern directly.

Correct Answer: B

Rationale: The correct answer is B because verbal abuse poses an immediate risk to the safety and well-being of others. Addressing this behavior first is crucial to ensure a safe therapeutic environment. The other choices, A, C, and D, do not pose an immediate threat to others' safety. Client A's behavior, although inappropriate, is not directly harmful to others. Client C's demand for attention may be disruptive but does not present an immediate safety concern. Client D's history of self-mutilation is concerning but does not indicate an immediate risk to others on the unit. Prioritizing the client diagnosed with conduct disorder who is verbally abusing a peer addresses the most urgent situation.