A nurse is reviewing the medical record of a client who performs self-injury.

Which of the following information should the nurse identify as placing the client at risk for self-harm behaviors?

The client has a history of bulimia nervosa.

The client has a parent who has dependent personality disorder.

The client has borderline personality disorder.

The client recently received a promotion at work.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

While bulimia nervosa can be associated with self-harm behaviors, it is not as strongly linked as borderline personality disorder.

Choice B rationale:

Having a parent with dependent personality disorder is not a specific risk factor for self-harm behaviors.

Choice C rationale:

Borderline personality disorder is strongly associated with self-harm behaviors.

Choice D rationale:

Receiving a promotion at work is generally considered a positive event and is not typically associated with an increased risk of self-harm behaviors.

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Correct Answer is D

Explanation

Choice A rationale:
High serum sodium levels do not directly cause toxic levels of valproate.
Choice B rationale:
While regular health monitoring is important, specifically performing thyroid function tests every 6 months is not a standard requirement for valproate use.
Choice C rationale:
A pretreatment electroencephalogram (EEG) is not typically required before starting valproate.
Choice D rationale:
Liver function tests must be monitored as valproate can cause liver failure that may be fatal.

A. Educating the client to the policies upon admission to the unit. B. Instructing the client that intrusive behaviors are not appropriate. C. Ensuring that the client's medication therapy is administered in a timely manner. D. Setting and maintaining consistent unit policies that are enforced by all staff.

Correct Answer is D

Explanation

Choice A rationale:
While educating the client about policies upon admission to the unit is important, it may not have the greatest impact on both the management of care and on milieu environment.
Choice B rationale:
Instructing the client that intrusive behaviors are not appropriate is important, but it may not have the greatest impact on both the management of care and on milieu environment.
Choice C rationale:
Ensuring that the client’s medication therapy is administered in a timely manner is crucial, but it may not have the greatest impact on both the management of care and on milieu environment.
Choice D rationale:
Setting and maintaining consistent unit policies that are enforced by all staff can create a stable and predictable environment, which can have a significant impact on both the management of care and on milieu environment.

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A nurse is reviewing the medical record of a client who performs self-injury. Which of the following information should the nurse identify as placing the client at risk for self-harm behaviors?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has bipolar disorder and a new prescription for valproate. Which of the following instructions should the nurse give the client about the use of this medication?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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A nurse is reviewing the medical record of a client who performs self-injury.

Which of the following information should the nurse identify as placing the client at risk for self-harm behaviors?