A client with borderline personality disorder reports to the nurse that they anxious & wants to cut their thigh. The nurse should first:

restrain the client to prevent self-harm

assist the client to identify the trigger situation and choose a coping strategy.

send the client to the crisis intervention unit for 23 hours of observation.

advise the client to take an anxiolytic to decrease their anxiety level.

Answer and Explanation

The Correct Answer is B

A. Restraining the client to prevent self-harm: While safety is a priority, physical restraint should be a last resort and not the first action taken in this scenario. It may escalate the situation and lead to feelings of loss of control.
B. Assist the client to identify the trigger situation and choose a coping strategy: This is the best initial intervention. Helping the client understand their triggers and encouraging the development of coping strategies can empower them and promote healthier responses to distress. This approach aligns with therapeutic practices that support emotional regulation.

C. Send the client to the crisis intervention unit for 23 hours of observation: While observation may be necessary if the client is at imminent risk of self-harm, it is essential first to explore the underlying issues and coping mechanisms. This action may be considered if the client remains a danger to themselves after initial interventions.

D. Advise the client to take an anxiolytic to decrease their anxiety level: Medications may help with anxiety, but this approach does not address the root of the problem or provide the client with skills to manage their distress. It is more beneficial to focus on therapeutic techniques first.

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Correct Answer is B

Explanation

A. Increased platelet count: While platelet activation can occur in unstable angina, an increased platelet count alone does not indicate heart damage. It is more relevant to thrombotic events than direct myocardial injury.

B. Elevated troponins: Troponin is a protein released when the heart muscle is damaged. Elevated levels are a key indicator of myocardial injury, making this a significant finding in the context of unstable angina.

C. Decreased homocysteine levels: Homocysteine levels are related to cardiovascular risk but are not directly indicative of heart damage. Elevated levels may suggest risk but do not confirm damage.

D. Elevated CK-MB: Creatine kinase-MB is an enzyme found in heart muscle. Elevated levels are indicative of myocardial injury, making this a relevant laboratory test for assessing heart damage in unstable angina.

E. Decreased alkaline phosphatase (ALT): Alkaline phosphatase is primarily related to liver and bone health and does not indicate heart damage. Decreased levels of ALT (alanine aminotransferase) are not relevant to myocardial injury.

A. increased fluid in the pericardial sac. B. dysfunction of one or more heart valves. C. an aneurysm of the descending aorta. D. an occlusion of the right coronary artery.

Correct Answer is B

Explanation

A. increased fluid in the pericardial sac: While fluid accumulation can affect heart sounds, it typically leads to muffled heart sounds rather than a loud murmur. Increased fluid in the pericardial sac (pericardial effusion) usually does not produce a classic heart murmur.

B. dysfunction of one or more heart valves: This statement is correct. Heart murmurs are often caused by turbulence in blood flow due to the dysfunction of heart valves, such as stenosis (narrowing) or regurgitation (leaking). A loud murmur suggests significant turbulence, which is often indicative of valvular heart disease.

C. an aneurysm of the descending aorta: While an aortic aneurysm can cause other types of heart sounds or signs of cardiovascular compromise, it is not primarily associated with heart murmurs.

D. an occlusion of the right coronary artery: An occlusion may lead to ischemia or myocardial infarction, which can cause changes in heart sounds, but it does not directly cause a heart murmur. Murmurs are more specifically related to blood flow dynamics, particularly involving valves.

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A client with borderline personality disorder reports to the nurse that they anxious & wants to cut their thigh. The nurse should first:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is reviewing the chart of a client with a diagnosis of unstable angina. Which laboratory test(s) result(s) should the nurse recognize as an Indication of heart damage? (SELECT ALL THAT APPLY)

Correct Answer is B

Explanation

The nurse auscultates a loud heart murmur while performing a cardiac assessment on a client. The nurse is aware that a heart murmur reflects:

Correct Answer is B

Explanation

The nurse is assisting a client diagnosed with hypertension with menu selection. Which items should the nurse suggest?

The nurse, who is assessing a client with peripheral vascular disease, notes that the client has no hair on the legs and has thick toenails. Which statement best describes the cause of this finding?

Isosorbide mononitrate modified release formula is structured to provide a nitrate free period. The nurse understands that the rationale for this period is to:

Which statement, made by a client receiving pharmacologic therapy for hypertension, indicates a need for further clarification by the nurse?

The client with coronary artery disease asks the nurse. "Why do I get this chest pain?" Which would be the most appropriate response?

The nurse is reviewing the laboratory test results of a client with long standing hypertension. Which result would be of most concern to the nurse?

The nurse caring for the client diagnosed with sickle cell crisis places priority on which specific goal(s) prior to discharge? (SELECT ALL THAT APPLY)