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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Twisting tongue movements are a common symptom of tardive dyskinesia (TD), a side effect of long-term use of antipsychotic medications like fluphenazine.
Choice B rationale:
Shuffling gait is more commonly associated with Parkinson’s disease and certain antipsychotic medications can cause Parkinson-like symptoms, but it is not a characteristic of TD2.
Choice C rationale:
Sudden onset of high fever is not associated with TD. It could be a sign of a serious condition like neuroleptic malignant syndrome, which requires immediate medical attention.
Choice D rationale:
Constant tapping of feet when sitting could be a sign of restlessness or akathisia, another potential side effect of antipsychotic medications, but it is not a specific sign of TD2.
Correct Answer is B
Explanation
Choice A rationale:
Pseudoparkinsonism is a side effect of antipsychotic medications that mimics the symptoms of Parkinson’s disease, such as tremors and rigidity. It does not typically cause hyperpyrexia or diaphoresis.
Choice B rationale:
Neuroleptic malignant syndrome is a rare but serious side effect of antipsychotic medications. It can cause severe fever (hyperpyrexia), unstable blood pressure, and heavy sweating (diaphoresis)4.
Choice C rationale:
Acute dystonia is a condition of sudden, involuntary muscle contractions. It does not typically cause hyperpyrexia or diaphoresis.
Choice D rationale:
Tardive dyskinesia is a side effect of long-term use of antipsychotic medications, causing involuntary movements, especially around the mouth. It does not typically cause hyperpyrexia or diaphoresis.
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