A nurse is creating a plan of care for a client who has borderline personality disorder. Which of the following actions should the nurse include in the plan?

Assess the client for triggers of self-mutilating behavior.

Encourage the client to use splitting behaviors.

Assist the client in developing more dependent relationships.

Use sympathy when developing the therapeutic relationship with the client

Answer and Explanation

The Correct Answer is A

A. Assess the client for triggers of self-mutilating behavior: Clients with borderline personality disorder are at risk for self-harm. Identifying triggers helps the nurse implement preventive strategies, provide timely interventions, and promote safety, which is a critical component of care planning.

B. Encourage the client to use splitting behaviors: Splitting, or viewing people as all good or all bad, is a maladaptive coping mechanism. Encouraging this behavior would worsen interpersonal relationships and is not therapeutic.

C. Assist the client in developing more dependent relationships: Borderline personality disorder involves unstable and intense interpersonal relationships. Promoting dependence is counterproductive; the goal is to foster healthy, balanced relationships and coping strategies.

D. Use sympathy when developing the therapeutic relationship with the client: Sympathy can reinforce maladaptive behaviors and dependency. Therapeutic relationships should focus on empathy, consistency, and clear boundaries rather than sympathy.

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Correct Answer is A

Explanation

A. A 24-year-old male who has a casted femur fracture: Long bone fractures, particularly of the femur, are the most common cause of fat embolism syndrome (FES). Fat globules can enter the bloodstream from the bone marrow, leading to respiratory, neurologic, and dermatologic manifestations. Young adults are at higher risk due to the frequency of high-energy trauma.

B. A 10-year-old female who has an ulnar fracture in an external fixator: FES is rare in small bone fractures such as the ulna, especially in children. The risk is minimal because less marrow fat is released into circulation compared with long bones like the femur.

C. A 45-year-old male who has multiple rib fractures: Rib fractures carry a low risk for FES because they involve flat bones with less marrow fat. The primary complications are respiratory in nature, such as pneumothorax or pulmonary contusion.

D. A 62-year-old female who has vertebral fractures due to osteoporosis: Vertebral fractures in older adults rarely result in FES because the marrow fat released is minimal, and low-energy trauma is usually involved. Other complications, such as spinal cord injury or chronic pain, are more likely.

A. Determine the client's airway patency B. Evaluate the client's level of consciousness. C. Auscultate the client's lung sounds. D. Ask the client to rate their pain.

Correct Answer is A,C,B,D

Explanation

A. Determine the client's airway patency: Ensuring the airway is patent is the highest priority in the immediate postoperative period because airway compromise can be life-threatening. This assessment is performed first to address the most critical physiological need.

B. Evaluate the client's level of consciousness: After airway and basic respiratory assessment, the nurse evaluates the client’s level of consciousness to detect neurological changes, sedation effects from anesthesia, or potential complications.

C. Auscultate the client's lung sounds: Respiratory assessment, including auscultation, identifies complications such as atelectasis or pneumonia. While vital, it follows confirming airway patency to prioritize immediate safety.

D. Ask the client to rate their pain: Pain assessment is important for comfort and recovery but is performed after addressing airway, breathing, and neurological status. It is lower priority compared with immediate physiological needs.

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A nurse is creating a plan of care for a client who has borderline personality disorder. Which of the following actions should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on an orthopedic floor is completing the morning assessments on several clients. Which of the following clients has the greatest risk for fat embolism syndrome (FES)

Correct Answer is A

Explanation

60. A nurse on a medical surgical unit is receiving a client who is postoperative following a laparotomy. In which order should the nurse perform the following actions? (Move the steps, placing them in the order of performance. Use all the steps.)

Correct Answer is A,C,B,D

Explanation

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