A nurse on a mental health unit is planning care for a client who has a new diagnosis of non- suicidal self-harm (NSSH). Which of the following interventions should the nurse include in the plan?

Explain to the client that self-harm behaviors do not increase their risk for accidental death.

Inform the client that self-harm behavior cannot become a serious problem in the future.

Encourage the client to identify the emotions they feel immediately before performing the self- harm behavior.

Place the client in one-on-one direct observation due to overt suicidal intent.

Answer and Explanation

The Correct Answer is C

C Encouraging the client to identify the emotions they feel immediately before performing the self-harm behavior is an important intervention. It can help the client develop insight into triggers and underlying emotions that contribute to the behavior. Identifying and addressing these emotions can be a crucial step in developing healthier coping mechanisms.

A. It is crucial to convey the potential risks associated with self-harm and emphasize the importance of seeking help and safer coping strategies.

B. Non-suicidal self-harm is a significant concern that requires attention and appropriate intervention. While NSSH does not necessarily indicate immediate suicidal intent, it can indicate significant distress

D. NSSH does not necessarily indicate suicidal intent, and placing the client in constant observation without clinical justification may be intrusive and undermine therapeutic rapport.

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Correct Answer is C

Explanation

C. Agranulocytosis is a serious side effect associated with clozapine, an antipsychotic medication. Agranulocytosis is characterized by a severe reduction in the number of white blood cells (specifically granulocytes) in the bloodstream, leading to an increased risk of infection. The client should be educated to monitor for signs and symptoms of agranulocytosis, including sore throat, fever, chills, and muscle aches, as these may indicate an underlying infection due to neutropenia.

A. Severe restlessness may be a side effect of some antipsychotic medications, but it is not specifically associated with agranulocytosis.

B. Respiratory depression and a comatose state are not typical manifestations of agranulocytosis.

D. Increased anxiety and suicidal ideations may be symptoms of certain mental health conditions or adverse effects of psychiatric medications, but they are not characteristic of agranulocytosis.

A. When discharged from the hospital B. When attending dialectical behavior therapy C. When attending narrative therapy D. When getting married

Correct Answer is A

Explanation

A. Individuals with borderline personality disorder (BPD) often experience intense and unstable emotions, impulsivity, and difficulties in regulating their emotions and behaviors. As a result, transitions, such as being discharged from the hospital, can be particularly challenging and may increase the risk of self-harm or suicidal behavior.

B. While dialectical behavior therapy (DBT) is an evidence-based treatment for BPD and focuses on teaching coping skills to manage emotions and reduce self-harming behaviors, attending therapy sessions may actually decrease the risk of self-harm for individuals actively participating in treatment.

C. Narrative therapy is another therapeutic approach that focuses on helping individuals reframe their life stories and experiences. While narrative therapy may be beneficial for some aspects of BPD treatment, it may not specifically address the immediate risk factors for self-harm.

D. Getting married may be a significant life event that brings about both positive and negative emotions, but it does not inherently indicate the highest risk for self-harm in individuals with BPD.

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A nurse on a mental health unit is planning care for a client who has a new diagnosis of non- suicidal self-harm (NSSH). Which of the following interventions should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is educating a client who is prescribed clozapine. Which of the following findings should the nurse identify as consistent with agranulocytosis and instruct the client to monitor?

Correct Answer is C

Explanation

A nurse is discussing borderline personality disorder and the risk for self-harm with a newly licensed nurse. Which of the following situations should the nurse identify as the highest risk for self-harm?

Correct Answer is A

Explanation

A nurse is caring for a client who is experiencing periods of hyperactivity, impulsivity, and inattentiveness. Which of the following medications should the nurse anticipate the provider to prescribe?

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A nurse is interviewing a client who states, "I am at a total loss and don't know what to do anymore. I feel hopeless." Which of the following responses should the nurse make?

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