Which of the following is the priority action by the nurse for a client with symptoms of depression who admits to thoughts of self-harm with a plan, and has a history of borderline personality disorder, depression, and substance abuse?

Review the client's toxicology laboratory report.

Initiate suicide precautions.

Administer the Hamilton Depression Scale.

Make a contract with the client for behavior in the unit.

Answer and Explanation

The Correct Answer is B

Choice A reason:

While reviewing the client's toxicology laboratory report is important to understand any substance use that may be contributing to the client's current state, it is not the immediate priority. The priority is to ensure the client's safety.

Choice B reason:

Initiating suicide precautions is the most critical and immediate action when a client admits to thoughts of self-harm with a plan. This involves creating a safe environment, providing constant supervision, and possibly removing harmful objects to prevent the client from acting on these thoughts.

Choice C reason:

Administering the Hamilton Depression Scale can help in assessing the severity of depression, but it is not the first priority. The immediate concern is to protect the client from self-harm.

Choice D reason:

Making a contract with the client for behavior in the unit can be a useful part of the treatment plan, particularly for clients with borderline personality disorder. However, it is not the first action to take when a client is at immediate risk for self-harm.

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Correct Answer is ["A","C","D"]

Explanation

Choice A reason:

Tremors are a common symptom of alcohol withdrawal and represent one of the body's physical responses to the lack of alcohol after a period of heavy drinking. These involuntary shaking movements typically occur in the hands but can affect other parts of the body.

Choice B reason:

Hyperglycemia, or high blood sugar, is not a typical symptom of alcohol withdrawal. In fact, hypoglycemia, or low blood sugar, is more commonly associated with alcohol withdrawal due to the depletion of glycogen stores in the liver.

Choice C reason:

Insomnia is another frequent symptom of alcohol withdrawal. Individuals often experience sleep disturbances, including difficulty falling asleep, staying asleep, and experiencing restful sleep, as the body adjusts to the absence of alcohol.

Choice D reason:

Visual hallucinations can occur during alcohol withdrawal, particularly in severe cases known as delirium tremens. These hallucinations can be distressing and may include seeing objects, patterns, or figures that are not present.

Choice E reason:

Severe hypotension is not typically a direct symptom of alcohol withdrawal. While blood pressure may fluctuate during withdrawal, severe low blood pressure is not commonly reported and could indicate other medical issues.

A. "You should try to see your partner's point of view before your own." B. "Tell me more about the concerns that you have regarding your marriage." C. "We could develop a plan for how to talk about this with your partner." D. "Relationship difficulties are stressful and require effort to resolve."

Correct Answer is A

Explanation

Choice A reason:

This statement may require intervention by the charge nurse because it suggests the nurse is taking a directive approach, potentially overstepping professional boundaries. It implies that the client's perspective is less important than their partner's, which could undermine the therapeutic relationship and the client's sense of autonomy.

Choice B reason:

Asking the client to elaborate on their concerns is a therapeutic communication technique that encourages expression and exploration of feelings. It does not require intervention as it is supportive and facilitates the nurse-client relationship.

Choice C reason:

Offering to help the client develop a plan to discuss their concerns with their partner is a constructive approach that empowers the client. It promotes problem-solving and does not necessitate intervention by the charge nurse.

Choice D reason:

Acknowledging that relationship difficulties are stressful and require effort to resolve is an empathetic statement that validates the client's experience. It is supportive and does not require intervention.

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Which of the following is the priority action by the nurse for a client with symptoms of depression who admits to thoughts of self-harm with a plan, and has a history of borderline personality disorder, depression, and substance abuse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is withdrawing from alcohol. Which of the following findings should the nurse expect? (Select all that apply).

Correct Answer is ["A","C","D"]

Explanation

Which of the following statements by the nurse requires intervention by the charge nurse when a client is sharing concerns about their marriage?

Correct Answer is A

Explanation

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