A nurse is caring for a client who has borderline personality disorder and has been engaging in self-mutilation. The nurse should encourage the client to participate in which of the following groups?

Co-dependents support group

Dual diagnosis treatment group

Desensitization therapy

Dialectical behavior treatment group

Answer and Explanation

The Correct Answer is D

Dialectical behavior therapy (DBT) is an evidence-based intervention that helps clients who have borderline personality disorder and self-harm behaviors to develop coping skills, emotional regulation, and interpersonal effectiveness.

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Correct Answer is A

Explanation

A WBC count of 13,000/mm indicates infection, which is a common cause of delirium in older adults. Delirium is an acute confusional state that can result from various factors, such as medications, metabolic disturbances, sensory impairment, or environmental changes. Neuropathy, BUN 16 mg/dL, and hypertension are chronic conditions that do not directly cause delirium, although they may contribute to the client's overall health status.

A. Obtain the provider's prescription within 60 min. B. Document the client's behavior every 15 min. C. Monitor the client's vital signs every 4 hr. D. Offer the client food and fluids every 2 hr.

Correct Answer is B

Explanation

Choice A reason:

Obtaining the provider's prescription within 60 min is not the immediate action required in this scenario. The priority is to ensure the safety of the client and others, which is achieved by continuous monitoring and documentation.

Choice B reason:

Documenting the client's behavior every 15 min is crucial in managing physically aggressive clients in seclusion. This allows the healthcare team to monitor the client's condition closely and make necessary interventions promptly.

Choice C reason:

Monitoring the client's vital signs every 4 hr may not be frequent enough for a client in seclusion who has been physically aggressive. The client's condition could change rapidly, and more frequent monitoring might be necessary.

Choice D reason:

Offering food and fluids every 2 hr is important for maintaining the client's physical health, but it is not the primary action in managing a physically aggressive client in seclusion. The immediate focus should be on ensuring safety and managing the client's aggressive behavior.

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A nurse is caring for a client who has borderline personality disorder and has been engaging in self-mutilation. The nurse should encourage the client to participate in which of the following groups?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a long-term care facility is caring for a client. The nurse should identify that which of the following conditions places the client at an increased risk for developing delirium?

Correct Answer is A

Explanation

A nurse has placed a client who has become physically aggressive into seclusion. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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