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 C

Explanation

The correct answer is c. Replace fluids.

Choice A Reason: Apply restraints

Applying restraints is generally not the first-line intervention for managing alcohol withdrawal. Restraints should only be used if the patient poses an immediate threat to themselves or others and all other less restrictive measures have failed. The primary focus in the initial phase of alcohol withdrawal is to manage physiological stability and prevent complications.

Choice B Reason: Identify social supports

While identifying social supports is important for long-term recovery and overall mental health, it is not the highest priority during the initial phase of alcohol withdrawal. The immediate concern is to address the acute physiological symptoms and prevent severe complications such as seizures or delirium tremens.

Choice C Reason: Replace fluids

Replacing fluids is the highest priority in the initial phase of alcohol withdrawal. Dehydration is a common issue in patients undergoing withdrawal, and maintaining fluid balance is crucial for preventing complications. Ensuring adequate hydration helps stabilize the patient and supports overall physiological function during the withdrawal process.

Choice D Reason: Orient to reality

Orienting the patient to reality is important, especially if they are experiencing confusion or delirium. However, it is not the highest priority in the initial phase of alcohol withdrawal. The primary focus should be on stabilizing the patient’s physiological condition, including fluid replacement and monitoring vital signs.

A. The patient’s partner’s act of sending flowers is an example of undoing. B. The patient and partner are in the honeymoon phase of intimate partner violence. C. The patient has a submissive personality and depression. D. Since the injuries have caused hospitalization, the patient will end the relationship. E. The partner may be trying to manipulate the staff by buying pizza.

Correct Answer is ["A","B","E"]

Explanation

The correct answer is a, b, and e.

Choice A Reason:

The patient’s partner’s act of sending flowers is an example of undoing. Undoing is a defense mechanism where a person tries to cancel out or remove an unhealthy, destructive, or otherwise threatening thought or action by engaging in contrary behavior. In this case, the partner is attempting to make amends for the abuse by sending flowers, which is a common tactic used by abusers to mitigate their guilt and manipulate the victim into forgiving them.

Choice B Reason:

The patient and partner are in the honeymoon phase of intimate partner violence. The cycle of abuse in intimate partner violence typically includes a honeymoon phase, where the abuser may apologize, show remorse, and promise to change. This phase often involves gestures of affection and kindness, such as sending flowers or gifts, to win back the victim’s trust and prevent them from leaving.

Choice C Reason:

The patient has a submissive personality and depression. While it is possible that the patient may have a submissive personality and depression, this conclusion cannot be definitively made based on the given scenario alone. Submissive personality traits and depression are complex and require thorough psychological evaluation to diagnose accurately.

Choice D Reason:

Since the injuries have caused hospitalization, the patient will end the relationship. This conclusion is not necessarily accurate. Victims of intimate partner violence often face significant psychological, emotional, and practical barriers to leaving an abusive relationship, even after severe incidents that result in hospitalization. The decision to leave an abusive relationship is influenced by various factors, including fear, financial dependence, emotional attachment, and lack of support.

Choice E Reason:

The partner may be trying to manipulate the staff by buying pizza. Manipulative behavior is common in abusive relationships. By buying pizza for the staff, the partner may be attempting to create a favorable impression and gain sympathy, which can influence the staff’s perception of the situation and potentially affect their support for the patient.

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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

The highest priority nursing action relative to the initial phase of alcohol withdrawal would be to:

Correct Answer is C

Explanation

Correct Answer is ["A","B","E"]

Explanation

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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: