Medical History: Borderline personality disorder.

Alcohol use disorder.

History of suicidal ideation.

Medication Administration Record: Fluoxetine 20 mg PO daily.

Nurses' Notes: . 1500: Client admitted for evaluation and treatment following arrest for driving while under the influence of alcohol.

Client reports recent breakup of romantic relationship and subsequent job loss.

States, "I was too upset to go to work, and then they fired me. Like I needed that stress, too.”. 1700: Noted client has multiple cuts on arms and legs and there is a broken mirror with blood on it on the floor.

Client states, "I feel so alone.

There is no one that cares about me.”. For each potential nursing action, click to specify if the potential action is anticipated, nonessential, or contraindicated for the client.

Instruct the client to avoid foods with tyramine.

Apply wrist restraints.

Offer sympathy and attention to maladaptive behavior.

Encourage the client to talk about feelings prior to maladaptive behavior.

Maintain same staff members caring for the client.

Answer and Explanation

The Correct Answer is F

Choice A rationale:
Instructing the client to avoid foods with tyramine is not relevant in this case. Tyramine is associated with certain antidepressants known as MAOIs, but the client is taking Fluoxetine, which is an SSRI2.
Choice B rationale:
Applying wrist restraints might be necessary in extreme situations to ensure the client’s safety, but it should be a last resort and not the first response to self-harm.
Choice C rationale:
Offering sympathy and attention to maladaptive behavior could reinforce negative behaviors and is not recommended.
Choice D rationale:
Encouraging the client to talk about feelings prior to maladaptive behavior can be beneficial. It can help the client develop healthier coping mechanisms.
Choice E rationale:
Maintaining the same staff members caring for the client can provide consistency and stability, which can be beneficial for individuals with Borderline Personality Disorder.
Choice F rationale:
Initiating suicide precautions is crucial in this situation. The client has a history of suicidal ideation and is exhibiting self-harming behavior.
Choice G rationale:
Offering the client opportunities for physical exercise can be beneficial as it can help manage stress and improve mood.
Choice H rationale:
Exploring feelings of abandonment with the client can be beneficial. It can help the client process these feelings in a healthier way.

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Correct Answer is D

Explanation

Choice A rationale:
Continuing to abstain from alcohol is a positive step towards maintaining mental health, not a sign of suicidal ideation.
Choice B rationale:
Finding therapeutic activities like walking around the hospital grounds is a positive coping mechanism, not a sign of suicidal ideation.
Choice C rationale:
Looking forward to future events like seeing grandchildren is a positive sign and not indicative of suicidal ideation.
Choice D rationale:
Giving away possessions, like a pottery collection, can be a sign of suicidal ideation as it may indicate the client is putting their affairs in order.

A. Ask the client direct questions about the hallucination. B. Instruct the client to argue with the voices that are a part of the hallucination. C. Act to the client as if the hallucination is real. D. Tell the client that the hallucination is not a part of reality.

Correct Answer is D

Explanation

Choice A rationale:
Asking direct questions about the hallucination may validate the hallucination as real in the client’s mind.
Choice B rationale:
Instructing the client to argue with the voices could potentially increase the client’s distress.
Choice C rationale:
Acting as if the hallucination is real may reinforce the client’s belief in the hallucination.
Choice D rationale:
Telling the client that the hallucination is not a part of reality can help ground the client in reality.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on an inpatient mental health unit is caring for a client who was admitted for suicidal ideation. Which of the following statements by the client should the nurse identify as a continuation of suicidal ideation?

Correct Answer is D

Explanation

A nurse is caring for a client who has schizophrenia and is experiencing a hallucination. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is reviewing medication records for several clients who have bipolar disorder. The nurse should recognize that which of the following medications are used to treat clients who have bipolar disorder.(Select all that apply.).

A nurse is caring for a young adult client who has acute schizophrenic disorder and tells the nurse, "Yesterday noon the sun moon went over the rover to see the lawnmower.”. Which of the following manifestations is the client exhibiting?

A nurse is reviewing abnormal laboratory values for four clients who have schizophrenia and take clozapine. For which of the following clients should the nurse withhold the medication and notify the provider immediately to have clozapine therapy discontinued?

Your patient is experiencing extrapyramidal symptoms (EPS) from antipsychotic therapy. You understand that the following medications are used to reverse EPS. (Select All that Apply.).

A nurse is caring for a client who has schizophrenia and is experiencing a variety of hallucinations. Which of the following hallucinations is the priority for the nurse to address?

A nurse is assessing for the presence of extrapyramidal side effects (EPS) in a client who is taking chlorpromazine. Which of the following findings should the nurse recognize as EPS? (Select all that apply.).

A nurse is caring for a client who has bipolar disorder and is in the manic phase. The client says he is bored. Which of the following activities is appropriate for the nurse to suggest to this client?