The nurse reviewed the nurses’ notes, provider’s note, and vital signs at 0415.

Exhibits

Which of the following interventions should the nurse include in the client’s care? Select the three interventions the nurse should implement.

Limit visitation from the client’s family.

Reorient the client to person, place, and time frequently.

Rotate nursing staff daily.

Approach the client slowly.

Maintain a low-stimulation environment.

Answer and Explanation

Correct Answer : B,D,E

Choice A reason: Limiting visitation from the client’s family may not be beneficial as the presence of familiar people can often help reorient and calm the client. Family members can provide comfort and reassurance, which can be particularly helpful for a client experiencing delirium.
Choice B reason: Reorienting the client to person, place, and time frequently is a recommended intervention for patients with delirium. This can help reduce confusion and agitation in clients with delirium.
Choice C reason: Rotating nursing staff daily could potentially increase confusion for the client, as continuity of care and familiar faces can be beneficial in managing delirium. Therefore, this option is not recommended.
Choice D reason: Approaching the client slowly is a recommended intervention for patients with delirium. Given the client’s agitation and confusion, it’s important to approach them in a non-threatening manner to avoid escalating their distress.
Choice E reason: Maintaining a low-stimulation environment is a recommended intervention for patients with delirium. A calm and quiet environment can help reduce agitation and confusion in clients with delirium.

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Correct Answer is D

Explanation

Choice A reason:
The statement "Inability to maintain employment" is not a primary characteristic of borderline personality disorder (BPD). While individuals with BPD may struggle with maintaining employment due to emotional instability and interpersonal difficulties, this is not a defining feature of the disorder.

Choice B reason:
The statement "Reluctance to discard worthless objects" is more indicative of hoarding disorder, not BPD. Hoarding disorder involves persistent difficulty discarding or parting with possessions, regardless of their actual value.

Choice C reason:
The statement "Avoidance of interpersonal relationships" is more characteristic of avoidant personality disorder. Individuals with BPD often have intense and unstable relationships rather than avoiding them.

Choice D reason:
The statement "Intense efforts to avoid abandonment" is the correct response. A hallmark of BPD is the fear of abandonment and frantic efforts to avoid real or imagined abandonment. This can lead to unstable relationships and emotional distress.

A. "Have you noticed that your taste has decreased?" B. "Have you noticed a ringing in your ears?" C. "Have you noticed an increase in thirst?" D. "Have you noticed unintentional weight loss?"

Correct Answer is C

Explanation

Choice A reason:
The statement "Have you noticed that your taste has decreased?" is not a common side effect of olanzapine. Olanzapine is an atypical antipsychotic used to treat schizophrenia and bipolar disorder. Common side effects include weight gain, drowsiness, and increased appetite, but changes in taste are not typically reported.

Choice B reason:
The statement "Have you noticed a ringing in your ears?" is also not a common side effect of olanzapine. Tinnitus (ringing in the ears) is not associated with olanzapine use. More common side effects include dizziness, dry mouth, and constipation.

Choice C reason:
The statement "Have you noticed an increase in thirst?" is the correct response. Olanzapine can cause hyperglycemia (high blood sugar), which can lead to increased thirst and urination. Monitoring for signs of hyperglycemia is important in clients taking olanzapine.

Choice D reason:
The statement "Have you noticed unintentional weight loss?" is not typical for clients taking olanzapine. In fact, weight gain is a more common side effect of olanzapine, along with increased appetite.

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The nurse reviewed the nurses’ notes, provider’s note, and vital signs at 0415. Exhibits Which of the following interventions should the nurse include in the client’s care? Select the three interventions the nurse should implement.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a mental health clinic is assessing a client who has borderline personality disorder. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

A nurse is obtaining a history from a client who has been taking olanzapine to treat schizophrenia. Which of the following questions should the nurse ask the client?

Correct Answer is C

Explanation

A nurse is caring for a client who is experiencing active auditory hallucinations. Which of the following actions should the nurse take?

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A nurse is caring for a client who has bipolar disorder and is refusing to take prescribed medications. Which of the following ethical principles is the nurse displaying when he supports the client's refusal of medications?

The nurse reviewed the nurses’ notes, provider’s note, and vital signs at 0415.

Exhibits

Which of the following interventions should the nurse include in the client’s care? Select the three interventions the nurse should implement.