A nurse on a mental health unit is caring for a client.

Exhibits

The nurse is contributing to the plan of care for the client. Which of the following actions should the nurse recommend? (Select all that apply.)

Establish consequences for unacceptable behaviors.

Encourage the client to verbalize their feelings.

Provide clear boundaries for behavior toward peers and staff members.

Determine if the client is having thoughts of harming themselves or others.

Bargain with the client when setting behavioral expectations.

Instruct the client on coping mechanisms and relaxation techniques.

Answer and Explanation

Correct Answer : A,B,C,D,F

A. Establish consequences for unacceptable behaviors: This approach helps the client understand the impact of their actions and encourages accountability, which is important for behavior management in borderline personality disorder.
B. Encourage the client to verbalize their feelings: Encouraging the expression of feelings helps the client develop better emotional awareness and communication skills, which are essential for managing their emotions and interpersonal relationships.
C. Provide clear boundaries for behavior toward peers and staff members: Setting clear boundaries is crucial for maintaining a safe environment and helps the client understand acceptable behavior, promoting healthier interactions with others.
D. Determine if the client is having thoughts of harming themselves or others: Regular assessment of self-harm and harm to others is essential, especially given the client's history of self-injury and a recent suicide attempt. This ensures the client's safety and allows for timely intervention if needed.
E. Instruct the client on coping mechanisms and relaxation techniques: Teaching coping strategies and relaxation techniques equips the client with tools to manage anxiety and emotional distress, which are common in borderline personality disorder.
F. Bargain with the client when setting behavioral expectations: Bargaining may reinforce manipulative behaviors and does not provide the structure that clients with borderline personality disorder often need. Instead, establishing firm and consistent expectations without negotiation is more beneficial for their treatment.

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Correct Answer is B

Explanation

A. Administer a benzodiazepine to the client: While benzodiazepines may be useful for managing anxiety, the first step in caring for a client with a dissociative disorder is to build a trusting relationship. Medications should not be prioritized over establishing rapport.
B. Establish rapport with the client: Building rapport is crucial in creating a safe environment for the client. It allows the nurse to gain the client’s trust, facilitating effective communication and treatment. A strong therapeutic alliance is essential for the client's willingness to engage in further interventions.
C. Teach the client grounding techniques: While grounding techniques can be beneficial for clients experiencing dissociation, they are most effective when the client feels safe and supported. Establishing rapport first will help the client be more receptive to learning and practicing these techniques.
D. Educate the client about their disorder: Education is important, but it should come after establishing a trusting relationship. The client may not be open to education about their disorder until they feel comfortable with the nurse and the therapeutic process.

A. To treat pain and ease anxiety B. To promote sleep and rest C. Because they witnessed their parents using drugs or alcohol to cope D. To treat hallucinations and perform better at work

Correct Answer is A

Explanation

A. To treat pain and ease anxiety: The client has a history of chronic back pain due to a gymnastics injury and a previous diagnosis of anxiety. It is common for individuals with chronic pain conditions to be prescribed opioids for pain relief. Additionally, those experiencing anxiety may misuse opioids to self-medicate and achieve temporary relief from their symptoms, leading to the development of an opioid use disorder.
B. To promote sleep and rest: While some individuals may use opioids in an attempt to promote sleep, this option does not directly address the client's specific history of chronic pain and anxiety. It is less likely to be a primary reason for starting opioid use compared to treating pain and anxiety.
C. Because they witnessed their parents using drugs or alcohol to cope: Although witnessing parental substance use can influence a person's behavior, there is no indication in the provided information that the client has this background. Therefore, this is not a clear underlying reason for the client's opioid use.
D. To treat hallucinations and perform better at work: There is no mention of the client experiencing hallucinations, and the context suggests that the client is struggling academically rather than seeking to perform better at work. This option does not align with the client's situation or history.

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A nurse on a mental health unit is caring for a client. Exhibits The nurse is contributing to the plan of care for the client. Which of the following actions should the nurse recommend? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a dissociative disorder. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

Correct Answer is A

Explanation

A nurse is caring for a client who has avoidant personality disorder. Which of the following types of therapy should the nurse anticipate for the client?

A nurse in an emergency department is collecting data from a client who has a personality disorder and reports that they recently used illicit drugs. Which of the following screening tools should the nurse use to determine if the client has recently used an illicit substance?

A nurse is caring for a client who has a serious mental illness and has developed tardive dyskinesia from anti-psychotic medication use. Which of the following adverse effects from anti-psychotic medication use would be expected for the client?

A nurse is discussing common misconceptions regarding clients who have substance use disorder. The nurse should include which of the following as a potential negative result of providers believing that addiction is the client's own fault?

A nurse is caring for a client who has been diagnosed with schizophrenia. The client has been wearing the same clothes for the past week and appears unkempt and unbathed. Which of the following statements should the nurse make to the client?

A nurse is caring for a client who has schizophreniform disorder. Which of the following manifestations should the nurse expect?

A nurse is discussing the three clusters of personality disorders. Which of the following personality disorders is part of cluster C?

A nurse is educating a group of clients about addiction. The nurse should include that which of the following factors increases the potential for addiction?

A nurse on a mental health unit is caring for a client.

Exhibits

The nurse is contributing to the plan of care for the client. Which of the following actions should the nurse recommend? (Select all that apply.)