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 D
Explanation
Choice A rationale:
Drinking green tea does not directly cause lithium toxicity.
Choice B rationale:
Moderate exercise does not directly cause lithium toxicity.
Choice C rationale:
Increasing sodium intake does not directly cause lithium toxicity. In fact, a sudden decrease in sodium intake can increase the risk of lithium toxicity.
Choice D rationale:
Experiencing diarrhea can lead to dehydration, which increases the risk of lithium toxicity by reducing the excretion of lithium.
Correct Answer is D
Explanation
Choice A rationale:
Diarrhea is not a specific reason to stop lithium. However, severe diarrhea can affect lithium levels and should be reported to a healthcare provider.
Choice B rationale:
Lithium does not need to be taken on an empty stomach. It can be taken with or without food.
Choice C rationale:
A low-salt diet is not recommended while on lithium. In fact, a consistent, normal sodium intake is important because low sodium levels can cause lithium levels to become too high.
Choice D rationale:
Regular blood tests are necessary when taking lithium to ensure therapeutic levels and prevent toxicity. Weekly blood tests may be required during the first month of treatment.
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