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A nurse in a mental health clinic is assessing a client who has a history of seeking counseling for relationship problems. The client shows the nurse multiple superficial selfinflicted lacerations on their forearms.

The nurse should identify these behaviors as characteristics of which of the following personality disorders?

Borderline

Antisocial

Paranoid

Histrionic

Answer and Explanation

The Correct Answer is A

Borderline.

A. Borderline personality disorder is characterized by a pervasive pattern of instability in interpersonal relationships, self-image, and affect, as well as marked impulsivity and recurrent suicidal behavior. The client's history of seeking counseling for relationship problems and selfinflicted lacerations are consistent with this disorder. Therefore, this choice is correct.
B. Antisocial personality disorder is characterized by a disregard for and violation of the rights of others, as well as a lack of remorse for one's actions. The client's behavior does not indicate this disorder. Therefore, this choice is incorrect.
C. Paranoid personality disorder is characterized by a pervasive distrust and suspiciousness of others, as well as a tendency to interpret others' motives as malevolent. The client's behavior does not indicate this disorder. Therefore, this choice is incorrect.
D. Histrionic personality disorder is characterized by excessive emotionality and attentionseeking behavior, as well as a tendency to dramatize situations and exaggerate emotions. The client's behavior does not indicate this disorder. Therefore, this choice is incorrect.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Incorrect. Obtaining capillary blood glucose level every 2 hr is appropriate for a client who has type 1 diabetes mellitus, but it does not address the ankle injury.
B. Incorrect. Checking the neurovascular status of the client's lower extremities every hour is important for a client who has an ankle injury, but it does not require clarification with the provider.
C. Correct. Applying a cold pack to the client's ankle for 30 min every hour can reduce swelling and inflammation, but it can also impair circulation and increase the risk of tissue damage in a client who has diabetes mellitus. Therefore, the nurse should clarify this prescription with the provider before implementing it.
D. Incorrect. Maintaining the affected ankle elevated and immobilized can help prevent further injury and promote healing, but it does not require clarification with the provider.

A. The nurse places the client on airborne precautions. B. The nurse has the client wear a mask for transport to radiology. C. The nurse wears an N95 respirator when performing client care. D. The nurse ensures the client's room maintains a positive airflow.

Correct Answer is D

Explanation

A. The nurse places the client on airborne precautions: This is appropriate, as measles is transmitted via airborne particles. B. The nurse has the client wear a mask for transport to radiology: This is correct. A surgical mask minimizes the risk of spreading airborne pathogens during transport. C. The nurse wears an N95 respirator when performing client care: Correct. An N95 respirator is necessary for protection against airborne diseases like measles. D. The nurse ensures the client's room maintains a positive airflow: This is incorrect and requires intervention. Clients with airborne infections like measles must be placed in negative pressure rooms, which prevent contaminated air from escaping into other areas. Positive airflow increases the risk of transmission to others.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has type 1 diabetes mellitus and reports severe ankle pain after falling off a stepstool at home. Which of the following prescriptions should the nurse clarify with the provider?

Correct Answer is C

Explanation

A charge nurse is evaluating a newly licensed nurse who is caring for a client who has measles. For which of the following actions by the newly licensed nurse should the charge nurse intervene?

Correct Answer is D

Explanation

A nurse is preparing to transfer a client from the ICU to the medical floor. The client was recently weaned from mechanical ventilation following a pneumonectomy. Which of the following information should the nurse not include in the change-of-shift report?

A nurse is teaching a client who is at 20 weeks of gestation about how to manage heartburn. Which of the following instructions should the nurse include?

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A nurse is reviewing the medical record of a client who has a prescription for misoprostol for induction of labor.Which of the following findings is a contraindication for administration of this medication?

A nurse is creating an incident report due to an accidental omission of a client's dressing change during the previous shift. Which of the following statements should the nurse document on the incident report form?

A nurse is preparing to replace a client's transdermal fentanyl patch after 72 hr of use. After the nurse opens the packet containing the new pouch, the client declines to accept it. Which of the following actions should the nurse take?

A charge nurse notices that one of the nurses on the shift frequently violates unit policies by taking an extended amount of time for break. Which of the following statements should the charge nurse make to address this conflict?

A charge nurse is observing an assistive personnel perform delegated tasks. Which of the following actions by the AP requires the charge nurse to intervene?