A nurse is reinforcing discharge teaching with a client who has borderline personality disorder. The client reports being a single parent caring for two toddlers. Which of the following actions should the nurse take?
Notify child protective services.
Suggest the children live with other relatives.
Encourage the children to visit the psychiatric unit when the client is leaving.
Offer the client information about a support group for parents.
The Correct Answer is D
A. "Notify child protective services." Reporting to child protective services is only necessary if there is evidence of abuse, neglect, or an inability to provide adequate care. A diagnosis of borderline personality disorder alone does not warrant an automatic report.
B. "Suggest the children live with other relatives." Encouraging a client to relinquish custody without evidence of an inability to care for the children is not appropriate. Providing support and resources to enhance parenting skills is a more beneficial approach.
C. "Encourage the children to visit the psychiatric unit when the client is leaving." While family involvement is important, exposing young children to a psychiatric unit can be overwhelming and inappropriate. Alternative ways to support parent-child bonding should be considered.
D. "Offer the client information about a support group for parents." Support groups provide a structured environment for clients to share experiences, receive guidance, and develop coping strategies, which can help manage stress and improve parenting skills.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. School-age: Schizophrenia is rare in children, and early-onset cases before adolescence are uncommon. Symptoms that resemble schizophrenia in children often require further evaluation for other neurodevelopmental disorders.
B. Young adulthood: Schizophrenia typically manifests between late adolescence and early adulthood, usually between ages 18 and 25 in men and slightly later in women. This period is when individuals experience their first psychotic episode.
C. Preschooler: Schizophrenia is extremely rare in preschool-aged children. Symptoms such as hallucinations or disorganized behavior at this age are more likely related to other developmental disorders or trauma.
D. Older adulthood: Late-onset schizophrenia is rare, and when psychotic symptoms emerge in older adults, they are often due to conditions such as dementia, delirium, or medication effects rather than primary schizophrenia.
Correct Answer is C
Explanation
A. Inappropriate guilt is a common symptom of depression, but it does not involve false beliefs about being targeted. Clients with major depressive disorder may feel excessive guilt, but this differs from the fixed, false beliefs seen in delusions.
B. Mania is characterized by elevated mood, impulsivity, and hyperactivity rather than paranoid thoughts. While manic episodes may include grandiose delusions, the belief that a government agency is attempting to capture the client aligns more with persecutory delusions.
C. Delusions are fixed, false beliefs that persist despite evidence to the contrary. The client’s statement suggests a persecutory delusion, which is commonly seen in psychotic disorders, including severe depression with psychotic features.
D. Confusion involves disorganized thinking, memory impairment, or difficulty understanding surroundings, often seen in delirium or cognitive disorders. While delusions can contribute to disorganized thoughts, they are distinct from general confusion.
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