Edited Text
A client with borderline personality disorder reported to the nurse in the clinic that they feel empty and anxious. The client wants to cut their arms. The nurse should first:

Assist the client to identify the triggering situation and choose a coping strategy.

Send the client to the crisis intervention unit for 23 hours of observation.

Restrain the client to prevent self-harm.

Advise the client to take an anxiolytic to decrease their anxiety level.

Answer and Explanation

The Correct Answer is A

Choice A Reason: Assist the client to identify the triggering situation and choose a coping strategy

This is the correct answer. Assisting the client to identify the triggering situation and choose a coping strategy is a therapeutic approach that empowers the client to understand and manage their emotions. This intervention helps the client develop skills to cope with distressing feelings and reduces the likelihood of self-harm. It is essential to address the underlying issues and provide support in a constructive manner.

Choice B Reason: Send the client to the crisis intervention unit for 23 hours of observation

While sending the client to a crisis intervention unit may be necessary in some cases, it is not the first step. Immediate therapeutic intervention to help the client understand and manage their emotions is crucial. Observation alone does not address the underlying issues or provide the client with coping mechanisms.

Choice C Reason: Restrain the client to prevent self-harm

Restraint should be a last resort and only used when there is an immediate risk of harm that cannot be managed through other means. It is important to first attempt less restrictive interventions that help the client manage their emotions and behaviors.

Choice D Reason: Advise the client to take an anxiolytic to decrease their anxiety level

While medication can be part of the treatment plan, it should not be the first intervention. Addressing the client’s immediate emotional needs and helping them develop coping strategies is crucial. Medication can be considered as part of a comprehensive treatment plan but should not replace therapeutic interventions.

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Correct Answer is ["A","C","D"]

Explanation

a. Assist the client to develop more effective coping mechanisms

c. Identify community resources for the client to use in a crisis

d. Educate the family about providing a safe and structured environment for the client

Explanation of Choices

Choice A Reason: Assist the Client to Develop More Effective Coping Mechanisms

Developing effective coping mechanisms is crucial for clients with a history of suicide attempts. Coping strategies help individuals manage stress, anxiety, and other emotional challenges that may trigger suicidal thoughts. Effective coping mechanisms can include mindfulness practices, cognitive-behavioral techniques, and stress management skills. By assisting the client in developing these skills, nurses can help reduce the risk of future suicide attempts and improve the client’s overall mental health.

Choice B Reason: Have a One-to-One Sitter for Outpatient Use

While having a one-to-one sitter can be beneficial in an inpatient setting to provide constant supervision and ensure safety, it is not typically feasible or necessary for outpatient care. Outpatient settings focus more on empowering the client with skills and resources to manage their condition independently. Continuous supervision in an outpatient setting may not be practical and could hinder the client’s sense of autonomy and self-efficacy.

Choice C Reason: Identify Community Resources for the Client to Use in a Crisis

Identifying community resources is a vital intervention for clients with a history of suicide attempts. Community resources can include crisis hotlines, support groups, mental health clinics, and emergency services. Providing the client with information about these resources ensures they have access to immediate help during a crisis. This support network can be crucial in preventing future suicide attempts and providing ongoing emotional and practical support.

Choice D Reason: Educate the Family About Providing a Safe and Structured Environment for the Client

Family education is essential in the care of clients with a history of suicide attempts. Educating the family about creating a safe and structured environment can help reduce triggers and stressors that may lead to suicidal thoughts. This education can include removing potential means of self-harm, establishing routines, and promoting open communication. A supportive family environment can significantly enhance the client’s recovery and reduce the risk of future suicide attempts.

Choice E Reason: Isolate the Client from All Stressful Situations That May Precipitate a Suicide Attempt

Isolating the client from all stressful situations is not a practical or effective intervention. While it is important to minimize exposure to significant stressors, complete isolation is neither feasible nor beneficial. Instead, the focus should be on helping the client develop resilience and coping strategies to manage stress. Learning to navigate and cope with stress is a critical part of recovery and long-term mental health management.

A. I am so relieved that my family can be with me when I die. B. I will have pain medicine available when I need it. C. In a few months, I will be strong enough to travel to my cabin and go fishing. D. I will be able to be in my own bed and home until I die.

Correct Answer is C

Explanation

Choice A Reason: I am so relieved that my family can be with me when I die

This statement reflects an accurate understanding of hospice care. Hospice care often allows patients to be surrounded by their loved ones during their final days. It emphasizes comfort and support, ensuring that the patient is not alone.

Choice B Reason: I will have pain medicine available when I need it

This statement is also correct. One of the primary goals of hospice care is to manage pain and other symptoms to ensure the patient’s comfort. Pain management is a critical component of hospice care, and medications are readily available to address the patient’s needs.

Choice C Reason: In a few months, I will be strong enough to travel to my cabin and go fishing

This statement indicates a need for further education. Hospice care is typically provided to patients who have a life expectancy of six months or less and who are no longer seeking curative treatment. The focus is on comfort and quality of life rather than recovery or improvement in physical strength. The expectation of becoming strong enough to travel and engage in activities like fishing is unrealistic in the context of hospice care.

Choice D Reason: I will be able to be in my own bed and home until I die

This statement is accurate. Hospice care often allows patients to remain in their own homes, surrounded by familiar surroundings and loved ones. The goal is to provide a comfortable and supportive environment for the patient during their final days.

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Edited TextA client with borderline personality disorder reported to the nurse in the clinic that they feel empty and anxious. The client wants to cut their arms. The nurse should first:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a history of a suicide attempt has been discharged and is being followed in an outpatient clinic. What is/are the most appropriate nursing intervention(s)? (SELECT ALL THAT APPLY)

Correct Answer is ["A","C","D"]

Explanation

The nurse is caring for a client who has been placed on hospice care. Which statement by the client indicates a need for further education?

Correct Answer is C

Explanation

A nurse is teaching the parents of a child who has ADHD about methylphenidate. Which of the following statements should the nurse include in the teaching?

A nurse is providing teaching to a client about ways to improve their health. Which of the following modifiable risk factors should the nurse include? (Select All that Apply)

The nurse is providing discharge instructions to the client taking disulfiram. Which of the following items should the nurse teach the client to avoid?

The rationale for the nurse needing to be aware of their own feelings while working with the family experiencing domestic violence is best explained as:

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During intake assessment, the nurse is most likely to hear a client with major depressive disorder say which of the following statements about depression? (Select All that Apply.)

A nurse is caring for a client who reports that they have been eliminating specific foods from their diet in order to “eat clean.” The nurse should identify that this is an indication of which of the following conditions?

A client with bipolar disorder is refusing to take mood stabilizers due to weight gain. To increase the patient’s adherence to a medication regimen, what measures could the nurse teach the client? (SELECT ALL THAT APPLY)

Edited Text
A client with borderline personality disorder reported to the nurse in the clinic that they feel empty and anxious. The client wants to cut their arms. The nurse should first: