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 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.

A. Command hallucination. B. Tactile hallucination. C. Gustatory hallucination. D. Visual 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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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 talking with a client who has schizophrenia. Suddenly the client states, "I'm frightened. Do you hear that? The voices are telling me to do terrible things.”. Which of the following responses by the nurse is appropriate?.

Correct Answer is A

Explanation

A nurse is caring for a client who has schizophrenia and is experiencing a variety of hallucinations. Which of the following hallucinations is the priority for the nurse to address?

Correct Answer is A

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?