A nurse is admitting a client who has borderline personality disorder and is at risk for self-mutilation. Which of the following interventions should the nurse incorporate in the plan of care?

Provide additional attention to the client.

Apply mechanical restraints before administering medication.

Obtain a verbal contract from the client.

Limit staff members who work with the client.

Answer and Explanation

The Correct Answer is C

Choice A reason: Providing additional attention to the client can sometimes reinforce negative behaviors in individuals with borderline personality disorder. It is important to balance attention with promoting independence and self-regulation.

Choice B reason: Applying mechanical restraints before administering medication is not a standard practice and can be considered unethical and harmful. Restraints should only be used as a last resort when there is an immediate risk of harm to the client or others.

Choice C reason: Obtaining a verbal contract from the client is a therapeutic intervention that can help manage self-mutilation risks. This contract involves the client agreeing to communicate with staff before engaging in self-harm, which can help in developing trust and promoting safety.

Choice D reason: Limiting staff members who work with the client can help provide consistency and stability, which is beneficial for individuals with borderline personality disorder. However, it is not the primary intervention for preventing self-mutilation.

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Correct Answer is B

Explanation

Choice A reason:

Paranoid personality disorder is characterized by pervasive distrust and suspicion of others. Individuals with this disorder often believe that others are out to harm or deceive them, and they may be reluctant to confide in others due to fear that the information will be used against them. They may also bear grudges and be quick to perceive attacks on their character that are not apparent to others. This disorder does not typically involve attention-seeking behaviors or flirtatious and seductive actions.

Choice B reason:

Histrionic personality disorder is marked by a pattern of excessive emotionality and attention-seeking behavior. Individuals with this disorder often feel uncomfortable when they are not the center of attention and may engage in inappropriate sexually seductive or provocative behavior to draw attention to themselves. They may also exhibit rapidly shifting and shallow expressions of emotions, use their physical appearance to attract attention, and have a style of speech that is excessively impressionistic and lacking in detail. These characteristics align with the behaviors described in the scenario.

Choice C reason:

Narcissistic personality disorder involves a pervasive pattern of grandiosity, need for admiration, and a lack of empathy for others. Individuals with this disorder often have an inflated sense of their own importance and a deep need for excessive attention and admiration. They may exploit others to achieve their own ends and believe they are superior to others. While they do seek attention, their behaviors are more focused on achieving admiration and recognition rather than the flirtatious and seductive behaviors described in the scenario.

Choice D reason:

Antisocial personality disorder is characterized by a disregard for and violation of the rights of others. Individuals with this disorder may engage in deceitful, manipulative, or aggressive behavior and often have a history of criminal activity. They may also show a lack of remorse for their actions. This disorder does not typically involve attention-seeking behaviors or flirtatious and seductive actions.

A. Urinary retention B. Blurred vision C. Headache D. Bradypnea

Correct Answer is D

Explanation

Choice A reason:

Urinary retention can be a side effect of both diazepam and hydromorphone, but it is not typically life-threatening. While it should be monitored and addressed, it is not the most urgent concern compared to respiratory issues.

Choice B reason:

Blurred vision can occur with the use of diazepam and hydromorphone, but it is generally not an immediate threat to the client’s life. It should be reported and managed, but it is not the highest priority.

Choice C reason:

Headache is a common side effect of many medications, including diazepam and hydromorphone. While it can be uncomfortable and may need treatment, it is not usually a sign of a life-threatening condition.

Choice D reason:

Bradypnea, or slow breathing, is a serious side effect that can occur with the use of both diazepam and hydromorphone, as both medications depress the central nervous system. This can lead to respiratory depression, which is potentially life-threatening and requires immediate medical attention.

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A nurse is admitting a client who has borderline personality disorder and is at risk for self-mutilation. Which of the following interventions should the nurse incorporate in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who exhibits excessive attention-seeking behaviors, including acting flirtatious and seductive. The nurse should identify these behaviors as manifestations of which of the following personality disorders?

Correct Answer is B

Explanation

A nurse is assessing a client who takes diazepam for anxiety and hydromorphone for severe pain. Which of the following is the priority finding that the nurse should report to the provider?

Correct Answer is D

Explanation

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