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 A

Explanation

A. A nurse asks a client if they have any cultural beliefs the nurse needs to be aware of: This example demonstrates cultural competence as the nurse is actively seeking information about the client's cultural beliefs, practices, and preferences. It reflects an understanding that cultural factors can influence healthcare and the client-nurse relationship.

B. A nurse tells a client about the nurse's own cultural background: While sharing cultural information can be a part of building rapport, the focus of cultural competence is on understanding and respecting the client's cultural background, not necessarily sharing the nurse's own cultural background.

C. A nurse observes a client's actions and reports they do not see any cultural practices: This approach is limited, as cultural practices may not always be visible or evident in a clinical setting. Cultural competence involves actively seeking information from the client rather than making assumptions based on observations.

D. A nurse checks a client's chart for any notes on culture: While reviewing a client's chart for cultural information is part of cultural competence, it is not a complete approach. Direct communication with the client about their cultural beliefs and preferences is essential for a comprehensive understanding.

A. A Client diagnosed with hypomania who is speaking loudly on the unit B. A client diagnosed with mania who expressed active suicidal ideations C. A client with a history of mania who is pacing in the hallway D. A client diagnosed with hypomania who is complaining of pain

Correct Answer is B

Explanation

Client diagnosed with hypomania who is speaking loudly on the unit: While hypomanic individuals may exhibit increased energy and talkativeness, the urgency is lower compared to a client expressing active suicidal ideations. This client does not pose an immediate threat to themselves or others.

B. Client diagnosed with mania who expressed active suicidal ideations: This is the correct answer. A client with active suicidal ideations is at an elevated risk and requires immediate attention. Suicidal thoughts in the context of mania can be impulsive, and prompt intervention is crucial to ensure the client's safety.

C. Client with a history of mania who is pacing in the hallway: Pacing may be a symptom of mania, but without additional information about the client's current state and any potential immediate risks, the client expressing active suicidal ideations takes precedence.

D. Client diagnosed with hypomania who is complaining of pain: Pain complaints, in the absence of other urgent factors, do not take precedence over active suicidal ideations. The risk of harm to oneself or others is a higher priority.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is describing the concept of cultural competence to a newly licensed nurse. Which of the following examples should the nurse include?

Correct Answer is A

Explanation

A nurse on an in-patient unit received the report at 15:00 hours. Which client should the nurse see first?

Correct Answer is B

Explanation

A nurse on an inpatient psychiatric unit implements care by scheduling client activities, interacting with clients, and maintaining a safe therapeutic environment. These actions reflect which role of the nurse?

A client diagnosed with obsessive-compulsive disorder is admitted to a psychiatric unit. The client has an elaborate routine for toileting activities. Which would be an appropriate initial client outcome during the first week of hospitalization?

A nurse learns at report that a newly admitted client experiencing mania is demonstrating grandiose delusions. The nurse should recognize which client statement would provide supportive evidence of this symptom?

A charge nurse is instructing a newly licensed nurse about mental health disorders. Which of the following statements by the nurse indicates an understanding of mental health disorders?

A client diagnosed with brief psychotic disorder tells a nurse about voices telling him to kill the president. Which nursing diagnosis should the nurse prioritize for this client?

When working with individuals who have a personality disorder. The nurse is aware of the importance of incorporating which nursing measures. (Select all that apply).