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

Explanation

The correct answer is a. The client’s behavioral change is expected after the time period of medication.

Choice A Reason:

This choice is correct because fluoxetine, a selective serotonin reuptake inhibitor (SSRI), typically takes about 4 to 6 weeks to start showing its full effects. The client’s statement, “I feel like a great weight is off my chest,” indicates a positive response to the medication, which aligns with the expected timeline for SSRIs to improve mood and alleviate symptoms of depression. This behavioral change suggests that the medication is working as intended, helping to lift the depressive symptoms.

Choice B Reason:

This choice is incorrect and concerning. While it is true that some individuals may experience a temporary increase in energy before their mood improves, which could potentially increase the risk of suicide, the client’s positive statement does not necessarily indicate suicidal planning. It is important for healthcare providers to continuously monitor for any signs of suicidal ideation, but in this context, the client’s statement more likely reflects an improvement in their depressive symptoms.

Choice C Reason:

This choice is incorrect because there is no indication that the medication dosage should be decreased or that a mood stabilizer should be added. Fluoxetine is generally well-tolerated, and the client’s positive response suggests that the current dosage is effective. Mood stabilizers are typically used in the treatment of bipolar disorder, not major depressive disorder, unless there is a specific indication for their use.

Choice D Reason:

This choice is incorrect and indicates a misunderstanding of serotonin syndrome. Serotonin syndrome is a potentially life-threatening condition caused by excessive serotonin activity in the brain, often due to drug interactions or overdose. Symptoms include agitation, confusion, rapid heart rate, and high blood pressure4. The client’s statement of feeling relieved does not align with the symptoms of serotonin syndrome, which are generally severe and require immediate medical attention.

A. Is from another state and says they are here on a long vacation. B. Has a cell phone that is not working in the emergency department. C. Is accompanied by a family member who will not let the client answer questions. D. Speaks another language and is in need of an interpreter to translate. E. None F. None

Correct Answer is C

Explanation

d. Speaks another language and is in need of an interpreter to translate.

The correct answer is c. Is accompanied by a family member who will not let the client answer questions.

Choice A Reason: Is from another state and says they are here on a long vacation

This choice is not necessarily indicative of human trafficking. While being from another state and claiming to be on a long vacation might raise some questions, it is not a definitive sign of trafficking. Many people travel for various reasons, and this alone does not suggest that the person is a victim of human trafficking.

Choice B Reason: Has a cell phone that is not working in the emergency department

This choice is also not a strong indicator of human trafficking. A non-working cell phone can be due to many reasons, such as technical issues or lack of service. While traffickers may sometimes control their victims’ communication devices, this alone is not enough to suspect trafficking.

Choice C Reason: Is accompanied by a family member who will not let the client answer questions

This choice is a strong indicator of human trafficking. Traffickers often control their victims’ interactions with others, including healthcare providers. If a family member or companion is overly controlling and does not allow the client to speak for themselves, it raises a significant red flag for potential trafficking. This behavior is often seen in trafficking situations to prevent the victim from disclosing their true circumstances.

Choice D Reason: Speaks another language and is in need of an interpreter to translate

This choice is not a definitive sign of human trafficking. Many people who are not victims of trafficking may speak another language and require an interpreter. While language barriers can complicate communication, they do not alone indicate trafficking. However, if combined with other signs, it could contribute to a suspicion of trafficking.

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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:

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Naxlex Comprehensive Predictor Exams

A client with major depressive disorder has been taking fluoxetine, an SSRI, for 5 weeks. During the first outpatient visit, the client smiles and states, “I feel like a great weight is off my chest.” How should the nurse interpret this behavior change?

Correct Answer is A

Explanation

A nurse is providing care for a client who is malnourished and appears exhausted. What data would cause the nurse to suspect the client is a victim of human trafficking? The client:

Correct Answer is C

Explanation

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

In assessing a client diagnosed with borderline personality disorder, which characteristic would the nurse expect to observe?

Psychiatric care technicians (PCTs) are unlicensed assistive personnel that are an integral part of the acute care mental healthcare team. Which of the following choices would be an example(s) of overdelegation by the nurse to a PCT? The nurse directs the PCT to (Select All that Apply):

The intervention appropriate for a client who has been manipulating others and has a diagnosis of antisocial personality disorder is to:

A client is to receive a continuous Heparin infusion at s00 units per hour. Pharmacy supplies Heparin in a concentration of 25,000 units per 250mL of NSS. Calculate the rate at which the nurse should set the infusion pump.

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 client diagnosed with bipolar disorder is experiencing a severe depressive episode. Which client behavior would alert the nurse to the highest priority intervention? The client:

A nurse is caring for a client who has a binge-eating disorder. Which of the following statements should the nurse expect from this client?

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: