A client with borderline personality disorder reported to the nurse in the clinic that they feel empty and anxious and wants to cut their arms. The nurse should:
advise the client to take an anxiolytic to decrease their anxiety level.
restrain the client to prevent self-harm.
assist the client to identify the trigger situation and choose a coping strategy.
encourage the client use self-harm behaviors to release emotion.
The Correct Answer is C
C. Individuals with borderline personality disorder often struggle with intense emotions and may engage in self-harming behaviors as a maladaptive coping mechanism. Helping the client identify triggers for their distress and teaching them alternative coping strategies, such as mindfulness, grounding techniques, or distress tolerance skills, can empower them to manage their emotions in healthier ways.
A. Anxiolytic medications can help alleviate anxiety symptoms but they are not typically the first-line intervention for addressing acute distress in individuals with borderline personality disorder (BPD).
B. Restraint should not be the first response to a client expressing distress or suicidal ideation. Physical restraint should only be used as a last resort in situations where there is an imminent risk of harm to the client or others and should be implemented by trained professionals following established protocols.
D. Encouraging self-harm behaviors reinforces maladaptive coping strategies and can increase the risk of harm to the client. It is essential to provide support and interventions aimed at reducing self-harming behaviors.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C. Constricted pupils, also known as miosis, are a classic sign of opioid intoxication. Opioids act on opioid receptors in the brainstem, which can lead to pupillary constriction.
A. Lability of mood refers to rapid and unpredictable changes in mood, which is not a typical finding in opioid intoxication.
B. Hypervigilance is not typically associated with opioid intoxication. Instead, opioid intoxication tends to cause CNS depression, leading to symptoms such as drowsiness, sedation, and impaired consciousness.
D. Opioid intoxication typically causes respiratory depression rather than increased respirations. Opioids depress the central respiratory drive, leading to shallow, slow, or irregular breathing patterns.
Correct Answer is A
Explanation
A. Ginkgo biloba has been reported to have anticoagulant properties and may potentiate the effects of warfarin, increasing the risk of bleeding. Therefore, individuals taking warfarin should exercise caution when using ginkgo supplements and be monitored closely for signs of bleeding or changes in anticoagulant response.
B. Dandelion is not known to directly affect blood clotting or the action of warfarin.
C. Acai berry is a fruit commonly consumed for its potential antioxidant properties and health benefits. There is limited scientific evidence regarding the interaction between acai and warfarin.
D. Zinc supplementation is generally considered safe for most individuals and there is limited evidence to suggest that zinc significantly enhances the anticoagulant effects of warfarin.
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