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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Asking “What are the voices telling you to do?” shows empathy and concern without validating the hallucination.
Choice B rationale:
Asking “Why do you think you are hearing the voices?” might imply that the nurse is validating the hallucination.
Choice C rationale:
Telling the client “You need to understand that there are no voices.”. might make the client feel misunderstood.
Choice D rationale:
Telling the client “You need to tell the voices to leave you alone.”. is not recommended as it might validate the hallucination.
Correct Answer is A
Explanation
Choice A rationale:
Command hallucinations can direct the patient to harm themselves or others, making it the priority to address.
Choice B rationale:
Tactile hallucinations, while distressing, are not typically as immediately dangerous as command hallucinations.
Choice C rationale:
Gustatory hallucinations, while potentially disturbing, do not usually pose an immediate threat.
Choice D rationale:
Visual hallucinations, while potentially distressing, are not typically as immediately dangerous as command hallucinations.
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