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

Choice A Reason:

“I’d rather be dead than living like this. I do not want to be alive.”

This statement reflects a common symptom of major depressive disorder, which is suicidal ideation. Individuals with major depressive disorder often experience feelings of hopelessness and worthlessness, leading them to believe that life is not worth living. This statement is a clear indication of the severity of the individual’s depressive symptoms and the need for immediate intervention to ensure their safety.

Choice B Reason:

“If I can just keep ignoring feelings.”

This statement is less likely to be heard from a client with major depressive disorder. Ignoring feelings is a coping mechanism that some individuals might use, but it does not directly reflect the core symptoms of major depressive disorder, which include persistent sadness, loss of interest in activities, and significant impairment in daily functioning. Therefore, this choice is not as indicative of major depressive disorder as the other statements.

Choice C Reason:

“I deserve to be this way. I’ve not accomplished anything important in my life.”

This statement reflects feelings of guilt and worthlessness, which are common symptoms of major depressive disorder. Individuals with this disorder often have a negative self-view and believe that they are failures or that they deserve to suffer. This statement highlights the individual’s low self-esteem and the pervasive negative thoughts that characterize major depressive disorder.

Choice D Reason:

“This is a bad episode, but I will be well soon.”

This statement reflects a more optimistic outlook, which is less common in individuals with major depressive disorder. However, it can still be heard from some clients who experience episodic depression and have hope for recovery. This statement indicates that the individual recognizes their current state as temporary and believes in the possibility of improvement, which can be a positive sign in the context of treatment.

Choice E Reason:

“I am determined to fight this episode and get through it.”

This statement reflects a proactive and positive attitude towards managing depression, which is less characteristic of major depressive disorder. While determination and resilience are important for recovery, individuals with major depressive disorder often struggle with motivation and energy, making it difficult for them to adopt such a mindset. Therefore, this choice is less likely to be heard from a client with major depressive disorder.

A. Limit fluid intake to 1,000 mL of fluid per day. B. Adjust the dose if you feel out of control. C. Have serum lithium levels checked every 6 months. D. Do not reduce normal dietary sodium intake.

Correct Answer is D

Explanation

d. Do not reduce normal dietary sodium intake.

Explanation of Choices

Choice A Reason: Limit Fluid Intake to 1,000 mL of Fluid per Day

Limiting fluid intake to 1,000 mL per day is not recommended for clients taking lithium carbonate. Adequate hydration is crucial because lithium can affect kidney function and fluid balance. Dehydration can increase lithium levels in the blood, leading to toxicity. Therefore, clients should maintain normal fluid intake to ensure proper hydration and avoid complications.

Choice B Reason: Adjust the Dose if You Feel Out of Control

Clients should never adjust their lithium dose on their own. Lithium has a narrow therapeutic range, meaning the difference between an effective dose and a toxic dose is small. Any changes in dosage should be made under the supervision of a healthcare provider to avoid the risk of lithium toxicity or subtherapeutic levels. Self-adjusting the dose can lead to serious health risks.

Choice C Reason: Have Serum Lithium Levels Checked Every 6 Months

While regular monitoring of serum lithium levels is essential, checking levels every 6 months may not be sufficient. Initially, serum lithium levels should be checked more frequently, such as every 1 to 2 weeks, until stable therapeutic levels are achieved. After stabilization, levels are typically monitored every 3 to 6 months, depending on the patient’s clinical status and any changes in medication or health condition. Regular monitoring helps ensure the medication remains within the therapeutic range and prevents toxicity.

Choice D Reason: Do Not Reduce Normal Dietary Sodium Intake

Maintaining normal dietary sodium intake is crucial for clients taking lithium. Sodium levels in the body can affect lithium levels; a decrease in sodium intake can lead to higher lithium levels and increase the risk of toxicity. Conversely, an increase in sodium intake can lower lithium levels, reducing its effectiveness. Therefore, clients should be advised to maintain a consistent sodium intake to help stabilize lithium levels in the blood.

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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

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)

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

Explanation

A client who is prescribed lithium carbonate is being discharged from inpatient care. Which medication information should the nurse teach this client?

Correct Answer is D

Explanation

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.)

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The nurse has recently set limits for a client with borderline personality disorder. The client yells at the nurse, “You used to care about me. I thought you were wonderful. Now I can see that I was mistaken. You are hateful.” This outburst can be assessed as:

The nurse assesses that medication teaching about tricyclic antidepressants was understood when the client states:

A physician orders Lithium 1.2 grams/day in three divided doses PO for a client with bipolar disorder. The medication is supplied as 300 mg/5 mL. How much will the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

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: