What is the nurse's priority assessment for a patient with borderline personality disorder?
Suicidal or homicidal ideations
Sleep patern changes
Impulsive behaviours
Only support systems
The Correct Answer is A
Borderline personality disorder is a serious mental illness characterized by instability in mood, behaviour, and self-image. Patients with borderline personality disorder are at a high risk of self-harm, suicide, and impulsive behaviours. Therefore, the nurse's priority assessment should be to identify any suicidal or homicidal ideations, as these can be life-threatening emergencies. Once identified, appropriate interventions should be initiated, such as suicide precautions, crisis management, and referral to mental health professionals for further evaluation and treatment.
While sleep patern changes, impulsive behaviours, and support systems are also important aspects to assess in patients with borderline personality disorder, they are not the priority when compared to suicidal or homicidal ideations.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
False imprisonment is the unlawful restraint of a person against their will. In this situation, the nurse’s actions of placing the client in seclusion overnight because the unit is short-staffed and the client frequently fights with other clients may be considered false imprisonment if the client did not consent to being placed in seclusion and if there were no legal grounds for doing so.
Option a. Invasion of privacy refers to the violation of a person’s right to privacy.
Option b. Battery refers to the intentional and harmful or offensive touching of another person without their consent.
Option d. Assault refers to the intentional act of causing another person to fear immediate harm or offensive contact.
Correct Answer is D
Explanation
Refeeding syndrome is a potentially life-threatening complication that can occur when a person with anorexia nervosa or other forms of malnutrition begins to eat again after a period of starvation. It is characterized by electrolyte imbalances and fluid shifts that can lead to cardiovascular dysfunction, including heart failure and arrhythmias. Therefore, when caring for a patient with anorexia nervosa who is being refed, it is important for the nurse to closely monitor the patient’s cardiovascular system for signs of dysfunction.
Option a. Endocrine system dysfunction can occur in patients with anorexia nervosa, but it is not typically associated with refeeding syndrome.
Option b. Respiratory system dysfunction can occur in patients with anorexia nervosa, but it is not typically associated with refeeding syndrome.
Option c. Musculoskeletal system dysfunction can occur in patients with anorexia nervosa, but it is not typically associated with refeeding syndrome.
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