A nurse is collecting data from a group of clients in an acute care mental health facility. For which of the following findings should the nurse be most concerned regarding individual client safety?

A client who has borderline personality disorder and acts impulsively

A client who has avoidant personality disorder and becomes anxious in social situations

A client who has dependent personality disorder and clings to nursing staff

A client who has histrionic personality disorder and seeks constant attention

The correct answer is: a) A client who has borderline personality disorder and acts impulsively

Answer and Explanation

The Correct Answer is A

Choice A reason: Clients with borderline personality disorder (BPD) who act impulsively can be a significant safety concern. Impulsive behaviors in BPD can include self-harm, suicidal ideation, substance abuse, and other risky actions. These behaviors can pose immediate and severe threats to the client's safety and require close monitoring, intervention, and support from the healthcare team to manage and mitigate these risks effectively.

Choice B reason: While clients with avoidant personality disorder may experience significant anxiety in social situations, this typically does not pose an immediate threat to their physical safety. The primary concern with avoidant personality disorder is social isolation and the impact on their mental health and quality of life. Anxiety in social situations can be distressing, but it does not inherently lead to dangerous behaviors.

Choice C reason: Clients with dependent personality disorder often exhibit clingy and submissive behaviors, relying heavily on others for support and decision-making. While this can create challenges in managing boundaries and fostering independence, it is not typically associated with immediate safety risks. The focus of care for these clients is on building self-reliance and coping skills.

Choice D reason: Clients with histrionic personality disorder often seek constant attention and may display dramatic, exaggerated behaviors. While this can be disruptive and challenging in a therapeutic setting, it does not usually pose a direct threat to the client's safety. The primary concern is managing interpersonal dynamics and ensuring that the client's behaviors do not negatively impact the therapeutic environment.

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Correct Answer is B

Explanation

Choice A reason: Serum creatinine levels are commonly used to assess kidney function. While kidney function is important, it does not specifically evaluate nutritional status. Chronic alcohol use can impact multiple organs, but thiamine deficiency is a more direct concern related to nutritional status in these patients.

Choice B reason: Thiamine (vitamin B1) deficiency is a well-known complication of chronic alcohol use disorder. Alcohol interferes with the absorption and utilization of thiamine, leading to deficiencies that can cause severe neurological problems, such as Wernicke's encephalopathy and Korsakoff's syndrome. Monitoring thiamine levels is crucial in assessing and managing the nutritional status of clients with chronic alcohol use disorder.

Choice C reason: Urinalysis is a basic test that can provide information about kidney function and the presence of infections, among other things. However, it is not specifically useful in evaluating the nutritional status of a client with chronic alcohol use disorder. Nutritional deficiencies would not be directly assessed through a routine urinalysis.

Choice D reason: Erythrocyte sedimentation rate (ESR) is a non-specific marker of inflammation and is used to detect inflammatory conditions. While it can provide information on inflammatory processes, it does not directly assess nutritional status. The nutritional impact of chronic alcohol use disorder is more accurately evaluated by specific nutrient levels, such as thiamine.

A. The client goes to their room alone when they feel overwhelmed. B. The client displaces their feelings of self-harm until they talk to the provider. C. The client suppresses their feelings when they are angry. D. The client notifies the nurse when they want to harm themselves.

Correct Answer is D

Explanation

Choice A reason: Going to their room alone when feeling overwhelmed may indicate that the client is trying to manage their emotions, but it does not directly address the effectiveness of the safety contract. The goal of the contract is to ensure that the client seeks help and communicates their feelings of self-harm to a healthcare provider.

Choice B reason: Displacing feelings of self-harm until talking to the provider is not a clear indication of the contract's effectiveness. The client may still be at risk of self-harm if they do not have immediate access to the provider. The safety contract aims to encourage the client to seek help and communicate their feelings promptly.

Choice C reason: Suppressing feelings when angry is not a healthy coping mechanism and does not indicate the effectiveness of the safety contract. The contract should promote open communication and seeking help rather than suppressing emotions, which can lead to further distress and potential self-harm.

Choice D reason: Notifying the nurse when they want to harm themselves is a clear indication that the safety contract has been effective. The client is following the agreed-upon plan to seek help and communicate their feelings of self-harm, which is the primary goal of the safety contract. This behavior demonstrates that the client is taking steps to ensure their safety and seeking support from healthcare providers.

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A nurse is collecting data from a group of clients in an acute care mental health facility. For which of the following findings should the nurse be most concerned regarding individual client safety?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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