A nurse is caring for a client who has borderline personality disorder (BPD).
Check the 6 assessment findings that require immediate follow-up:.
Financial situation.
Increased use of mood-altering substances.
Sexual behaviors.
Hepatitis Viral Study (HAA) results.
BUN level.
Hgb level.
Sodium level.
Being admitted frequently
Recent loss of a parent
Correct Answer : B,C,D,G,H,I
Choice A rationale:
Financial situation is a concern but it does not require immediate follow-up in a medical context.
Choice B rationale:
Increased use of mood-altering substances is a serious concern. The client has been drinking heavily and asking for their “nerve” pill, which could indicate substance misuse.
Choice C rationale:
The client’s sexual behaviors, specifically having multiple partners and not using condoms, pose a risk for sexually transmitted infections.
Choice D rationale:
The positive Hepatitis Viral Study (HAA) indicates the presence of a viral hepatitis infection, which requires immediate medical attention.
Choice E rationale:
The BUN level is within the normal range (10 to 20 mg/dL), so it does not require immediate follow-up.
Choice F rationale:
The Hgb level is within the normal range (12 to 18 g/dL), so it does not require immediate follow-up.
Choice G rationale:
The sodium level is below the normal range (136 to 145 mEq/L), indicating hyponatremia, which requires immediate medical attention.
Choice H rationale:
The frequency of facility admissions indicates that the client’s condition is not being managed effectively and requires immediate reassessment.
Choice I rationale:
The recent loss of a parent is a significant life event that could exacerbate the client’s mental health issues and substance misuse, requiring immediate follow-up.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Fluvastatin is a medication used to treat high cholesterol. It is not used to treat mania in bipolar disorder.
Choice B rationale:
Lorazepam is a benzodiazepine used for treating anxiety, not typically used as a first-line treatment for mania.
Choice C rationale:
Carbamazepine is an anticonvulsant that is used as a mood stabilizer in the treatment of bipolar disorder. It can help reduce symptoms of mania.
Choice D rationale:
Propranolol is a beta-blocker used to treat high blood pressure and heart conditions. It is not typically used to treat mania in bipolar disorder.
Correct Answer is C
Explanation
Choice A rationale:
Group discussions about local elections can be stimulating and may exacerbate the client’s manic symptoms.
Choice B rationale:
Watching a video with a group in the day room may not provide enough engagement for a client in a manic phase.
Choice C rationale:
Walking with the nurse in the courtyard provides physical activity and one-on-one interaction, which can help manage energy levels and provide a calming influence.
Choice D rationale:
Participating in a basketball game in the gym could overstimulate the client and potentially lead to injury.
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