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. 2 inches 21 gauge: This option is too long and too large in gauge for subcutaneous administration. Typically, a longer needle is not necessary for subcutaneous injections, especially for standard adult adipose tissue.

B. 1 1/2 inch 27 gauge: While this gauge is acceptable, the length is still longer than typically required for subcutaneous injections. A 1 1/2 inch needle is more suited for intramuscular injections.

C. 5/8 inch 25 gauge: This is the most appropriate choice for a subcutaneous injection. A 5/8 inch needle is typically adequate for subcutaneous tissue in adults, and a 25 gauge needle provides a suitable size for comfort while allowing the medication to be administered effectively.

D. 1/4 inch 19 gauge: This option is not suitable for subcutaneous injections. A 1/4 inch length is too short for effective penetration into subcutaneous tissue, and a 19 gauge needle is larger than necessary, which could increase discomfort.

A. The chest pains caused by a spasm my heart." B. "I should not experience chest pain since I am on aspirin therapy." C. "I should hire someone to shovel snow in the winter D. "Each time I have chest pain my heart is damaged more."

Correct Answer is C

Explanation

A. "The chest pains caused by a spasm of my heart": This statement reflects a misunderstanding. Chronic stable angina is typically caused by myocardial ischemia due to atherosclerosis rather than spasms. While vasospasm can occur, it is not the primary cause of chronic stable angina.

B. "I should not experience chest pain since I am on aspirin therapy": This statement is misleading. Aspirin therapy helps reduce the risk of clot formation and subsequent heart attacks but does not eliminate angina. Patients may still experience angina symptoms during exertion or stress.

C. "I should hire someone to shovel snow in the winter": This statement indicates an understanding of the need to avoid excessive physical exertion that could trigger angina. Hiring someone to perform strenuous tasks like shoveling snow reflects a proactive approach to managing the condition and preventing potential angina episodes.

D. "Each time I have chest pain my heart is damaged more": This statement is overly alarmist. While recurrent angina can indicate underlying heart issues, occasional episodes of stable angina do not necessarily result in immediate, progressive heart damage.

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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

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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