A client with borderline personality disorder reports to the nurse that they anxious & wants to cut their thigh. The nurse should first:

restrain the client to prevent self-harm

assist the client to identify the trigger situation and choose a coping strategy.

send the client to the crisis intervention unit for 23 hours of observation.

advise the client to take an anxiolytic to decrease their anxiety level.

Answer and Explanation

The Correct Answer is B

A. Restraining the client to prevent self-harm: While safety is a priority, physical restraint should be a last resort and not the first action taken in this scenario. It may escalate the situation and lead to feelings of loss of control.
B. Assist the client to identify the trigger situation and choose a coping strategy: This is the best initial intervention. Helping the client understand their triggers and encouraging the development of coping strategies can empower them and promote healthier responses to distress. This approach aligns with therapeutic practices that support emotional regulation.

C. Send the client to the crisis intervention unit for 23 hours of observation: While observation may be necessary if the client is at imminent risk of self-harm, it is essential first to explore the underlying issues and coping mechanisms. This action may be considered if the client remains a danger to themselves after initial interventions.

D. Advise the client to take an anxiolytic to decrease their anxiety level: Medications may help with anxiety, but this approach does not address the root of the problem or provide the client with skills to manage their distress. It is more beneficial to focus on therapeutic techniques first.

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Correct Answer is C

Explanation

A. Neutrophils 57%: This value reflects the percentage of neutrophils in the white blood cell count and does not specifically indicate the effectiveness of iron therapy. It is more related to the body’s immune response.

B. International Normalized Ratio (INR) 13 seconds: INR is a measure of blood coagulation and is not directly related to iron levels or the treatment of anemia. Therefore, this result does not indicate the success of ferrous sulfate therapy.

C. Total reticulocyte count 2.2% of total RBC count: An increased reticulocyte count indicates that the bone marrow is producing more red blood cells, which is a positive response to iron supplementation. A reticulocyte count around this percentage suggests an appropriate response to therapy for iron deficiency anemia.

D. Platelet count 250,000/µL: This is a normal platelet count and does not provide information specific to the effectiveness of iron therapy. It does not reflect the state of anemia or the response to iron supplementation.

A. I usually wait about two hours after I feel chest discomfort to seek medical attention." B. "I know that I should carry my medication with me in case develop chest pain." C. "My wife and I will learn to cook using the "good" cooking das D. "I feel a little anxious when I get chest discomfort."

Correct Answer is A

Explanation

A) "I usually wait about two hours after I feel chest discomfort to seek medical attention.": This statement is particularly concerning as it suggests a dangerous delay in seeking help during a potentially critical situation. Waiting to seek medical attention for chest discomfort can indicate a lack of understanding of the seriousness of the symptoms, which may hinder effective adaptation to the illness and could result in severe health risks.

B) "I know that I should carry my medication with me in case I develop chest pain.": This statement shows that the client is aware of the importance of having their medication accessible during a potential cardiac event. It indicates a level of preparedness and understanding of their condition, suggesting that the client is adapting well to managing their illness.

C) "My wife and I will learn to cook using the 'good' cooking methods.": This statement reflects a proactive approach to lifestyle modifications, indicating that the client is willing to make dietary changes to improve their health. Such positive steps are a sign of adapting effectively to coronary artery disease.
D) "I feel a little anxious when I get chest discomfort.": While anxiety is a natural response to experiencing chest discomfort, this statement alone does not indicate an inability to adapt. Acknowledging feelings of anxiety can be part of a healthy coping mechanism as the client learns to manage their condition.

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A client with borderline personality disorder reports to the nurse that they anxious & wants to cut their thigh. The nurse should first:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client has recently started ferrous sulfate 500 mg by mouth two times per day for anemia. Which of the following data would indicate to the nurse that the therapy is successful?

Correct Answer is C

Explanation

Which statement, made by the client with coronary artery disease, alerts the nurse that the client may be experiencing difficulty adapting to the illness?

Correct Answer is A

Explanation

The nurse who is providing instructions to a client with hypertension will stress that it is most important to:

The nurse auscultates a loud heart murmur while performing a cardiac assessment on a client. The nurse is aware that a heart murmur reflects:

The nurse is conducting dietary teaching for a client diagnosed with coronary artery disease. Which statement made by the client indicates an understanding of fat sources and the need to limit saturated fats?

The nurse obtains a prescription for furosemide 40 mg IV for a client who has pulmonary congestion as the result of fluid volume overload. The nurse assesses the vital signs to be T-98.6, P-110, RR-24 and BP-90/60. What is the most appropriate action at this time?

The nurse is teaching a client with hypertension about the prescribed bumetanide, a loop diuretic, 1 mg PO daily. Which statement, made by the client would indicate that the teaching has been effective?

The nurse auscultates a heart murmur on a client with cardiovascular disease. At which anatomic landmark will an aortic murmur be heard the loudest?

The client with coronary artery disease asks the nurse. "Why do I get this chest pain?" Which would be the most appropriate response?

The client diagnosed with primary hypertension states, "I don't know why the doctor is worried about my blood pressure. I am feeling just fine." Which statement by the nurse would be the most appropriate response?