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 B

Explanation

A. Increase calcium in the diet: While calcium is important, it's not the most critical aspect in managing hypertension compared to weight management.

B. Monitor weight on a weekly basis: Weight management is crucial for clients with hypertension, as fluctuations can indicate changes in fluid retention or overall health. Regular monitoring can help in managing blood pressure.

C. Obtain blood pressure checks twice a year: This is insufficient for monitoring hypertension; more frequent checks are generally recommended.

D. Have yearly eye examinations: While important for overall health, it’s not as directly related to the management of hypertension as monitoring weight.

A. Bottle spoon-shaped finger nails B. Platelets 400.000/0 C. Rea blood cell count 4.5 million/mm3 D. Hemoglobin 8.0 g/di E. Tachypnea

Correct Answer is ["A","D","E"]

Explanation

A. Bottle spoon-shaped fingernails: This is a classic sign associated with iron deficiency anemia, known as koilonychia. The nails may appear thin, brittle, and spoon-shaped, indicating a deficiency in iron.

B. Platelets 400,000/µL: This platelet count is within the normal range (typically 150,000 to 450,000/µL) and does not specifically indicate iron deficiency anemia. Thus, it is not an expected finding.

C. Red blood cell count 4.5 million/mm³: This value is within the normal range for females (approximately 4.2 to 5.4 million/mm³). In iron deficiency anemia, one would expect the RBC count to be low or at least on the lower end of normal.

D. Hemoglobin 8.0 g/dL: This low hemoglobin level is indicative of anemia. In iron deficiency anemia, hemoglobin levels are often significantly decreased, so this finding aligns with the client's condition.

E. Tachypnea: Increased respiratory rate can occur in response to anemia, as the body attempts to compensate for decreased oxygen-carrying capacity by increasing breathing rate. Therefore, tachypnea is a likely finding in this client.

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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

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

Correct Answer is B

Explanation

A female client with iron-deficiency anemia is experiencing increased fatigue and a shiny red tongue. The nurse would anticipate seeing which additional assessment finding(s) (SELECT ALL THAT APPLY)

Correct Answer is ["A","D","E"]

Explanation

The nurse is reviewing the laboratory data of a client diagnosed with coronary artery disease. Which set of laboratory results indicates a need for client teaching regarding dietary modifications?

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?

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The nurse is working collaboratively with the physical therapist to develop an exercise program for a client recently diagnosed with hypertension. Which intervention would be best to assist the client in maintaining the exercise program?

Which statement, made by a client receiving pharmacologic therapy for hypertension, indicates a need for further clarification by the nurse?