A 19 year old patient has a diagnosis of Borderline personality disorder. The patient approaches the nurse and shows multiple fresh cuts on both arms. Which is the most therapeutic response by the nurse?

"After I clean your wounds, I would like for you to journal how you were feeling before you cut yourself.

I’m so sorry you cut your arms Let's discuss how you were feeling

Wow. what happened to you?".

What did you use to cut yourself! I will need to search your room

Answer and Explanation

The Correct Answer is A

A. "After I clean your wounds, I would like for you to journal how you were feeling before you cut yourself."

This response is the most therapeutic. It acknowledges the patient's self-harm behavior, addresses the immediate physical needs by offering to clean the wounds, and encourages the patient to reflect on their emotions through journaling. This approach promotes self-awareness and provides a constructive coping strategy.

B. "I’m so sorry you cut your arms. Let's discuss how you were feeling."

This response is empathetic and encourages communication about the patient's emotions. While it acknowledges the self-harm and invites discussion, it does not suggest a specific coping strategy like journaling. It is still a supportive and therapeutic approach.

C. "Wow. What happened to you?"

This response may come off as judgmental or dismissive. It does not acknowledge the patient's emotional state or offer immediate support for the physical wounds. The tone and wording may make the patient feel uncomfortable or judged.

D. "What did you use to cut yourself! I will need to search your room."

This response is not therapeutic and may be perceived as confrontational and invasive. It does not prioritize the patient's emotional well-being and may violate the patient's trust and privacy. Searching the room without consent is not a recommended approach.

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Correct Answer is D

Explanation

A. Histrionic Personality Disorder:

Individuals with histrionic personality disorder typically seek attention and may be overly dramatic, but self-harm as a response to perceived abandonment is not a characteristic feature.

B. Obsessive-Compulsive Personality Disorder (OCPD):

People with obsessive-compulsive personality disorder are characterized by perfectionism, preoccupation with details, and a desire for control. Michelle's behavior, including self-harm in response to perceived rejection, aligns more closely with borderline personality disorder.

C. Narcissistic Personality Disorder:

While narcissistic individuals may exhibit a sense of superiority and a desire for admiration, self-harm in response to abandonment is not a typical trait of narcissistic personality disorder.

D. Borderline Personality Disorder (BPD):

This personality disorder is characterized by unstable relationships, self-image, and emotions. Individuals with BPD may have intense fears of abandonment and engage in impulsive and self-destructive behaviors. Michelle's perception of being disliked, her claim of superiority, and the self-harming action in response to news of the nurse's vacation are consistent with BPD.

A. Dry mouth and urinary retention B. Akinesia and insomnia C. Sore throat, fever, and malaise D. Akathisia and hypersalivation

Correct Answer is C

Explanation

A. Dry mouth and urinary retention: These symptoms are not typically associated with the side effects of clozapine. Dry mouth is a common side effect of many antipsychotic medications, but urinary retention is not a typical side effect of clozapine.

B. Akinesia and insomnia: Akinesia (lack of movement) is not a common side effect of clozapine. Insomnia can occur with various antipsychotic medications but does not typically warrant immediate intervention unless severe or persistent.

C. Sore throat, fever, and malaise: These symptoms can indicate a potentially serious side effect known as agranulocytosis, which is a significant reduction in white blood cell count. Clozapine is associated with an increased risk of agranulocytosis. If a client experiences symptoms such as sore throat, fever, or malaise, it may indicate a severe drop in white blood cell count, and immediate medical attention is necessary.

D. Akathisia and hypersalivation: Akathisia (restlessness) is a known side effect of antipsychotic medications, but it is not typically associated with immediate severe medical risks. Hypersalivation is a common side effect but does not usually require immediate intervention unless severe.

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A 19 year old patient has a diagnosis of Borderline personality disorder. The patient approaches the nurse and shows multiple fresh cuts on both arms. Which is the most therapeutic response by the nurse?

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A client diagnosed with schizophrenia is prescribed clozapine (Clozaril). Which client symptoms related to the side effects of this medication should prompt a nurse to intervene immediately?

Correct Answer is C

Explanation

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