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

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.

A. If the client has a history of addictive behaviors B. Whether the client has had previous rehabilitation for alcoholism C. Their previous and current coping skills D. When the client last had a drink of alcohol

Correct Answer is D

Explanation

d. When the client last had a drink of alcohol

Explanation of Choices

Choice A Reason: If the Client Has a History of Addictive Behaviors

Assessing whether the client has a history of addictive behaviors is important as it provides insight into the client’s overall pattern of substance use and potential risk for relapse. However, while this information is valuable for developing a comprehensive treatment plan, it is not the most immediate concern during the initial admission assessment. The primary focus should be on identifying any immediate risks or needs, such as the potential for alcohol withdrawal.

Choice B Reason: Whether the Client Has Had Previous Rehabilitation for Alcoholism

Knowing whether the client has had previous rehabilitation for alcoholism can help the nurse understand the client’s treatment history and any previous interventions that may have been effective or ineffective. This information is useful for planning ongoing care and support. However, it is not the most critical factor to assess during the initial admission, as it does not directly address the client’s current physical and mental state.

Choice C Reason: Their Previous and Current Coping Skills

Evaluating the client’s previous and current coping skills is essential for understanding how they manage stress and triggers related to their alcoholism. This assessment can inform the development of personalized coping strategies and support mechanisms. Nonetheless, while important for long-term treatment planning, it is not the most urgent factor to assess during the initial admission.

Choice D Reason: When the Client Last Had a Drink of Alcohol

Determining when the client last had a drink of alcohol is the most important factor to assess during the initial admission. This information is crucial for predicting the onset of alcohol withdrawal symptoms, which can begin as early as 4 to 6 hours after the last drink. Early identification of potential withdrawal allows the healthcare team to implement appropriate monitoring and interventions to manage withdrawal symptoms and prevent complications. Alcohol withdrawal can be life-threatening if not properly managed, making this assessment a top priority.

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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 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

What is the most important factor for the nurse to assess when doing an admission assessment of a client with a history of alcoholism?

Correct Answer is D

Explanation

Several children come to the Emergency Department for treatment. The situation that would cause the nurse to have the highest suspicion of child abuse would be:

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 psychiatrist prescribes a monoamine oxidase inhibitor (MAOI) for a client. When teaching the client about food interactions with the medication, which foods will the nurse caution the client to avoid?

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

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:

The nurse is scheduled to interview a client with histrionic personality disorder. The nurse can anticipate that the assessment findings will include the following. The 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: